TIME MAGAZINE asks: HMO's? NO! * TIME MAGAZINE (Jan. 22, 1996) contained an excellent article on HMO's that should be read by all. The following is an editorial comment on that article.

* TO THE EDITOR:- Your article, "The Soul of an HMO" (TIME: Jan.22,1996) reveals some important problems with managed care in the United States.

These have developed because of interference with medical practice and economics by policymakers and social engineers. Most physicians have been aware of these problems for a long time, but they have been afraid to speak out against them for fear that they might lose their livelihoods.

Thus social and governmental pressures have served to undermine the ethics that have been part of the bedrock of American medicine. Once health care planners successfully switched the American public from thinking of their individual health care needs and responsibilities to a mindset of "our needs", "our health care dollars", "providers" instead of doctors and the like, such an outcome became inevitable.

I hope, however, that it is not irreversible. In 1994, after 23 years as a practicing Obstetrician-Gynecologist in Fairfield CT, I concluded that I could not practice in an ethical manner in a managed care environment and I closed my practice.

In the letter that I sent out to my patients notifying them of my decision I said in part, "...The truth of the matter is that the economic and regulatory climate in which medicine must now be practiced has made my personalized style and type of practice, in which I take great pride, extremely difficult.

Employers shift their workers (my patients) around from doctor to doctor, thinking only of how "cheap" a group insurance plan is and giving no thought at all to the physician-patient relationship.

Insurance companies appropriate to themselves, under the guise of the term "managed care", the right to refuse necessary care to patients in order to enhance their own profits.

Medically untrained lay persons, reading words they cannot pronounce from pre-programmed computer screens, tell physicians how to practice medicine..." These words continue to ring true every day, and the situation is getting worse.

Committees such as you describe in your article meet daily at managed care firms and make decisions such as: a) patients over age 72 are "too old" to qualify for coronary bypass surgery; b) aggressive cancer chemotherapy is "not economically justifiable" in patients over age 75.

Are these the proper criteria on which to base an individuals health care? I certainly don't think so. I believe that this is contrary to the very basis of American liberty and individualism.

Unfortunately, there is nothing new about managed care, managed competition, managed trade, or any other such policy-wonk creation. It is called Corporatism. In a bygone era it would have been called Fascism, but that term has become so associated with racial/ethnic hatred that most people forget that the underlying concepts of fascism were first and foremost economic. It is "the other Socialism".

As Americans we have become so inured to the canards of "the left" and "the right" (taken from the seating in the French Assembly) that we forget that economically and politically, Fascism and Communism are not opposites but are in fact, merely variations on the same theme of governmental control of the citizenry and its business.

If this is allowed to continue American physicians will eventually be called upon to decide which patients are "worthy of treatment, given our limited economic resources". This is completely contrary to traditional American medical ethics.

Fifty years ago we successfully fought a war to once and for all do away with the concept that some groups of people are "lebensunwertes Leben" - life unworthy of life itself. Let us not now bring these horrible, discredited concepts of economic "efficiency" to this country! Physicians now face a crossroads similar to that faced by the French after their country was overrun by Germany in W.W.II - where does appeasement end and collaboration begin?

For a doctor to join a small number of managed care plans in order to enhance the survival of his practice until things can be fixed is probably acceptable, even necessary, in today's climate. But to join as many plans as a doctor can get into, to accept whatever reimbursement is offered by the managed care firm without thought to the effort and resources expended, and to fail to defend a patient's right to the best possible care because a doctor is fearful of being "deselected" from the companies provider panel is inexcusable collaboration.

Sadly, even the AMA stands on the threshold of crossing the line. We stand at a dangerous crossroad in American medicine today. Let us not cross over the threshold into unethical and inhumane care.