Managed Care Needs Some Managing

Is managed care dangerous to your health? Is it unethical to ask doctors, nurses and patients to live with the constraints that managed care imposes? You might very well think so, given all the news media attention directed toward the subject in recent weeks.

Images of physicians with gags over their mouths on the covers of national news magazines do not do much for the blood pressure of managed-care administrators.

On television and in newspapers, we’ve seen exposes in which parents complain they cannot get their plan to cover the cost of a nurse for their sick child, and stories of people whose pharmacist tells them that the pills that were covered last week are not covered today. Such reports leave many people wondering how the managed-care industry might affect their health.

Part of the problem for the managed-care industry is that it is making bundles of money. Salaries and compensation for executives and administrators are often staggeringly high. Profits and returns to investors are, uh, robust.

Watching people who have nothing to do with the direct delivery of health care wallow in money is certain to draw the ire of doctors and hospitals, who resent this hemorrhage of money from their own pockets.

Putting aside the bickering over money, managed care is in itself neither bad nor immoral. It is simply a different way to pay for health care.

In the 1960s, ‘70s and ‘80s, doctors and hospitals got paid a fee for each service they provided. Today, managed-care plans pay a fixed amount of reimbursement annually for your care. Why the switch? Greed.

Under the old fee-for-service payment scheme, physicians, hospitals and well-insured patients made out like bandits. Despite years of warnings from business and government to get costs under control, they didn’t. Enter managed care.

We are now paying corporate executives lots of money to do what doctors, hospitals and well-insured patients would not: curb the appetite for more and more costly care.

Think of the managed-care industry as a personal trainer and yourself as an unhappy, bloated tub. The trainer’s job is to get you thin. The skinnier you get, the more money the trainer makes.

In that situation, would you feel safe not putting any limits or boundaries on what the trainer could do to get you in shape? I doubt it.

We need to decide what boundaries ought to apply to managed care. I humbly offer a few suggestions:

Government should demand full public disclosure from all managed-care plans in plain English about the nature of the care they give and the complaints that each plan accrues every year.

Managed-care plans should have some patients on their boards who can keep an eye on coverage and reimbursement decisions.

State authorities and insurance departments should be able to perform audits on demand, to check on quality of care and costs.

How about some minimal consumer protection, modeled after the regulations now used for the electric, water, gas and phone companies, whereby those with complaints can get a hearing?

Perhaps we should set limits on how much plans can earn or keep in their reserves.

Today you and I are at the mercy of a legion of business executives whom we hired to curb our health-care appetites. We need to be sure the “trainers” do not get too enthusiastic about their work lest we wind up dead.

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The following fields overflowed: CREDIT = Art Caplan King Features Syndicate