Disadvantages of the Managed Care

The cost of medical care in the U.S.A. is high, but no more so than in Japan. A citizen of Japan covered under the national health insurance system pays typically 10 to 30 percent of the cost because the balance is covered for those services that are recognized under the insurance, so to him/her, the out-of-pocket cost is actually one tenth to one third of the actual cost. In contrast, in the U.S.A., there is no such universal coverage. The patient is the party that is responsible for the payment of all charges incurred. This disparity makes the cost of care in the U.S.A. seem higher to a Japanese citizen who is covered by national health insurance.

If one is fortunate, prescient, and prudent enough to have purchased health insurance coverage prior to the onset of an illness, the policy will pay varying amounts for any particular illness depending on the contract, or policy. Usually, but not always, insurance policies that are more expensive cover a larger proportion of the cost of treatment of a wider variety of illnesses; and more expensive policies in general permit a wider selection of primary care physicians, specialists, and facilities. Conversely, if a person opts to purchase a less expensive policy, he/she will pay a larger proportion of the cost of a treatment, rendered by physicians and other providers that are specified by the insurance plan.

Health Maintenance Organizations, or HMO's, are prepaid health plans that need special mention because of its unique characteristics. The entire fiscal structure of these organizations is based upon the treatise that most efficient delivery of health care can be accomplished by pre-payment of all fees for services to those who deliver health care. For example, a physician is paid a "per member per month" fee, for a set number of individual "lives" no matter what happens. The physician has a fiscal advantage "incentive" to deliver care in lowest cost, or otherwise he will be earning less, a fiscal "disincentive." Referrals to specialists are provided at a "disincentive" to the primary treating physician, as are diagnostic tests and hospitalizations. This "risk-sharing" system has been the only method which has been repeatedly and consistently successful in controlling the increasing cost of medical care in this country. On the other hand, this system has been criticized for risking the well-being of the patient in the name of cost control.

At NIPPON MEDICAL CLINIC (Los Angeles), we have chosen not to participate in any prepaid health plans, or HMO's, for the above reason. Our philosophy is that every patient should be treated individually and not according to insurance company rules. Our physicians work on behalf of the patient, who is the consumer of health care, and not on behalf of the insurance company, who is the payer of the cost of such consumption. Our physicians recognize that, in the past, some physicians have ordered unnecessary tests or performed unnecessary procedures, which we feel is inexcusable. Our physicians are committed to delivering comprehensive, cost-effective, and first-rate medical care.

This is not to say that we live in a vacuum; we recognize that there are those individuals who can not pay for the medical care that is necessary for his/her well-being. For those patients who are in need of emergency medical care, our physicians would without hesitation, as we have done in the past, render emergency care, without regard to an individual's ability to pay. For those patients who can not afford to pay our clinic charges in full, discounted fees can be arranged. For those who are destitute and can not pay for any charges, referrals can be made to social agencies that can assist them.



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