A colleague of mine is a neurosurgeon. He once did a complicated surgery to remove a brain tumor. The patient's managed-care plan approved one day in the intensive-care unit following the surgery. That day came and went. The patient still had uneven breathing. Her blood pressure and heart rate continued to fluctuate dangerously, as is often the case after the brain is manipulated in surgery. The doctor decided she needed another day in the ICU: She still needed minute-by-minute monitoring and physiologic fine-tuning.

The doctor phoned her HMO to obtain approval for the extra day of ICU care. The HMO's utilization-review nurse consulted a guide book that outlined the HMO's policies for allowable treatments. It stated only one day was allowed in the ICU. So she denied the extra day. The doctor felt that it would be medically unacceptable to transfer the patient out of the ICU. He kept her there. The next day he was called by another utilization-review nurse from the HMO. She explained that since the second day of ICU care had not been approved, its cost would be deducted from his surgeon's fee. "You'd better transfer the patient out today," she warned. Then she made a joke: "If these ICU costs keep adding up, the deductions will surpass your fee. Not only won't you get paid for caring for the patient, you could wind up owing us money."

This demonstrates the most subtle method by which managed care limits care: It wages a battle of attrition. In this case, to get approval for the second part demanded hours of effort on the part of doctors and office staff. It required routing through the HMO appeal system, asking whom to appeal to next, making more and more phone calls, enduring seeming eternities placed on hold, writing and rewriting letters, filling out specialized treatment request forms. In all, a treatment request or appeal might require 10 or more hours on the part of the doctor and far more time from his or her office staff. The limited number of hours in the day demands that doctors pick their battles--not every treatment is worth such extraordinary effort. So managed care limits care by simply making it logistically difficult to obtain permission. Doctors fight for the truly important cases. But many times when there are smaller--though still real--benefits for the patient, doctors concede defeat.