Perpetuating the Myth: How Managed Care is Bad News for Pregnant Women

Patricia Salber

Posted 10/22/11 on The Doctor Weighs In

So, I just saw a Kevin Pho MD tweet flash by on my computer screen with the statement “Managed care is bad news for pregnant women.”  I clicked on the link in the tweet and was taken to his blog site.  Sure enough, there was an article with the title:  “How managed care is bad news for pregnant women” written by Linda Burke-Galloway, an obstetrician-gynecologist and author of The Smart Mother’s Guide to a Better Pregnancy.

Having worked for managed care most of my life, I know a lot about the good, bad, and ugly of managed care.  I am not an apologist for the industry, but neither am I a person who thinks the term “managed care” automatically connotes all things evil in health care.  I am a member of a managed care plan and am quite happy.

That being said, I was curious about what Dr. Burke-Galloway was going to say about managed care and bad news for pregnant women.  Here it is:

“Managed care is bad news for pregnant women. Extremely bad news. Every ultrasound, lab test and hospital admission that your physician or midwife orders on your behalf will have to be pre-approved by a gatekeeper who is on a mission to increase the profits of their company by reducing the amount of money that is spent on you. So you must therefore be on a mission to keep both you and your unborn baby out of harm’s way. How do you do that?”

Even if you think that all managed care companies only care about profits, the problem with Dr. B-G’s statement is pre-approving “every ultrasound, lab test, and hospital admission” isn’t all that big of a deal nowadays.  Most medically necessary tests and admissions will be approved, many automatically based on systems that use built in evidence-based guidelines. Furthermore, not all managed care programs require preapproval of the types of tests this doctor is referring to, but even if some do, there are benefits to the pre-approval process beyond “increasing the profits,” for example, reducing redundant, wasteful, testing – see what a Canadian Study showed with respect to overuse of prenatal ultrasounds – identifying people that could benefit from a case manager or social worker, avoiding hospitalizations that are not necessary and could expose the patient to nosocomial (hospital acquired) infections.

And, on the flip side, not having any oversight of services provided to patients can result in overutilization of testing and admissions, activities that drive up the cost of health care and are not without consequences to patients.  The oversight provides accountability…we all behave better when we know someone is watching…and it is one of the reasons why we are seeing a nation-wide interest in Accountable Care Organizations.

So, enough on whether managed care is good or bad.  What really annoyed me about this article (sorry it isn’t PC, but this article really annoyed me) was not the paragraph I reproduced above, but the fact that the rest of the article was not about perceived managed care abuses at all.  It was a list of things that pregnant women should do to “keep both you and your unborn baby out of harm’s way.”  If you study this list, you will find that almost all are things in the list are ones that relate to your doctor, not the insurance company.  Here is the list together with a couple of my comments thrown in for your consideration:

1. Research your prospective healthcare provider through your State Board of Medicine’s licensing department to make certain they do not have any 7-figure malpractice suits settled or pending [Almost all managed care companies do this type of doctor checking prior to admitting them into their network of providers]
2. If you’ve had a previous high-risk pregnancy, request a referral to a Maternal Fetal Medicine high-risk specialist for your prenatal care
3. If you delivered a preterm baby in the past, chances are likely you will do it again. Ask to have your cervix measured when you have an ultrasound and if it’s short , request  a referral to a high-risk specialist
4. If you have vaginal bleeding and are pregnant, do not leave a doctor’s office or an emergency room without someone doing an ultrasound to confirm that (a) the fetus is alive and (b) the pregnancy is not in the fallopian tubes (aka) ectopic pregnancy. An undiagnosed ectopic pregnancy could rupture and cause havoc. [This should be considered medically necessary and, therefore, paid for by insurance]
5. If you complain of a vaginal discharge, do not leave your healthcare provider until someone gives you a diagnosis and treatment. Untreated vaginal infections can lead to preterm labor. Bacteria is not your friend when you’re pregnant
6. Back and lower abdominal pain should not be ignored, especially if you are less than 36 weeks. It could represent signs of premature labor
7. Become familiar with fetal tracings. Flat lines and “u-shaped” curves during labor could mean your baby is in trouble and needs to be delivered quickly
8. Try to deliver in a hospital that has a level 3 nursery and/or a NICU (neonatal intensive care unit)
9. If a hospital mistreats you, contact its administrator. If you’re still not satisfied, file a complaint with the Joint Commission on Accreditation of Healthcare Organizations (JCAHO)
10. Trust your instincts. I can’t emphasize this enough.”

I am fine with blaming insurance companies when they act badly.  But not all of the problems in the health care industry  stem from managed care.  Let’s get real.

Pat Salber MD, MBA is a former Emergency Physician. She has served as Chief Medical Officer or Medical Director for several large health plans. She writes at the Doctor Weighs In.