Will managed medical care be hazardous to your health?
Will the cost-cutting forces of the marketplace overwhelm medical morality and put America at risk of losing the best health care in the world?
Dr. Jerome P. Kassirer, editor in chief of the influential New England Journal of Medicine, has sounded a warning about the dangers of imposing profit-driven systems of medical care on both physicians and patients. His predictions are chilling.
Enormous, well-financed corporations are already dominating health care delivery in many parts of the country, says Kassirer. Millions of people not yet enrolled in a managed care organization may be pushed into one soon.
As groups compete to reduce health-care costs - the better to expand, pay stockholders’ dividends and reward corporate executives - physicians are pressured to curtail care and patients are shortchanged.
“Market-driven care is likely to alienate physicians, undermine patients’ trust of physicians’ motives, cripple academic medical centers, handicap the research establishment and expand the population of patients without health-care coverage,” Kassirer predicts.
Some managed-care plans have been effective in reducing hospital stays, promoting day surgery and emphasizing preventive care, with savings a secondary benefit, not the primary goal, notes Kassirer.
But other managed-care corporations emphasize cost cutting in a variety of troubling ways. They recruit only the healthiest patients, such as employee groups. They ration care by making it inconvenient to get. And they deny services, by limiting what physicians can do.
As managed-care organizations grow and more people choose HMOs or are pushed into them by employers, physicians feel they must join, too, or lose most of their practice.
To join a plan, physicians may have to sign a contract agreeing to abide by its rules or be fired. Doctors may become trapped between what they consider the best care for their patients and the constraints of the organization.
This is particularly true in “capitated” systems in which patients (or their employers or insurers) pay a fixed amount regardless of the care they receive. Such plans also have financial incentives to spend as little as possible on care. Physicians may have their earnings cut if they prescribe too much costly treatment.
“The incentive to remain employed is so strong that many physicians in a capitated system may not provide all the services they should, may not always be the patient’s advocate and may be reluctant to challenge the rules governing which services are appropriate,” Kassirer says. “In fact, their contracts may forbid them to disclose the existence of services not covered by a plan.”
This can pose “excruciating quandaries” for physicians, Kassirer notes. “Soon, many of them will find themselves conforming to the restrictions and deceiving themselves that what they are doing is best for their patients.”
So who, then, stands up for the patient?
Employers usually can’t, or won’t, Kassirer says. The theory that managed-care plans would compete on the basis of quality of care as well as price doesn’t work because there are no reliable ways to measure quality of care. So employers are likely to choose plans for their employees largely on the basis of cost. To be competitive, plans will continue to cut expensive care and offer fewer services.
“Some plans with superb track records are being underbid by wealthy investor-owned plans,” Kassirer says. “It is only a matter of time before even the best plans will be forced to trim benefits to compete.”
It’s tempting to look for legislation to help. A few states are considering passing laws to stop hospitals and insurers from sending new mothers and newborns home in fewer than 48 hours.
Requiring plans to provide all “medically appropriate” and necessary care wouldn’t work, either, Kassirer explains. No such list of treatments exists. To use his example, what would arthroscopic knee surgery to restore the ability to play tennis be considered?
It’s also worrisome to have Congress and state legislators getting involved in medical decisions that should be made, without coercion, between physician and patient.
Another concern is that as managed-care plans squeeze hospitals and ratchet down costs, hospitals become increasingly unable to provide free care for the indigent - or to finance research and medical education.
The problem with the theory of a market-driven, managed-care system is that consumers - patients - have no real voice. They can’t opt out of a plan if their employer offers only one. They may have no useful way to compare plans if they have a choice. They may be too ill or medically unsophisticated to realize their doctors are not giving them the best care. And they may not be able to afford treatment outside of their plan.
Much of the savings being wrung out of health care at the expense of physicians and patients are going to pay for a new layer of administration, huge corporate salaries and investors’ profits. Treating patients is becoming just a business cost, to be kept as low as possible.
It’s simplistic to blame physicians and hospitals for much of the problem of skyrocketing health costs that has spurred the enormous growth of the managed care industry. It’s simplistic to argue they must be a big part of the solution to protect patients. But unless they stand up effectively for patients, who will?
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