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Perspectives |
1 From the Department of Radiological Sciences, UCI Medical Center, 101 The City Dr, Orange, CA 92868-3298. Received June 19, 2000; accepted July 5, 2000. Address correspondence to the author (e-mail: rmfriede@uci.edu).
Index terms: Perspectives • Radiology and radiologists, socioeconomic issues
I have previously expressed my opinions on how managed health care has affected the practice of medicine (1,2). As with any major change, an analysis of the positive and negative effects takes several years. In 1997, Simon et al (3) surveyed 2,700 medical students, residents, faculty members, and deans (80% response rate) on their attitude toward managed care. In general, the respondents reported that fee-for-service medicine provided better access to patients, fewer ethical conflicts, better doctor-patient relationships, better continuity of care, and better care for patients with chronic illness than did managed care. Managed care was considered better than fee-for-service in providing preventive medicine, coordination of care, cost-effectiveness, and decreasing duplication or unnecessary care. It was of interest that most of the respondents stated that they would prefer a single-payer system over the plethora of managed care plans.
Before the technologic revolution in medicine in the 1950s and 1960s, the relationship of the patient to the physician was one of confidence and trust. When technology led to superspecialization and patients were referred to consultants for diagnosis and therapy, the patient’s identification with the primary care physician suffered, and trust in the physician decreased. When managed care restricted patient access and available resources, the patients believed that the physician had lost control of health care.
Trust in the physician is an important part of the healing process. Managed care is based on the distributive ethic, but an ill patient is concerned with his or her own illness rather than community health. If the patient believes that the physician is not totally concerned with the patient’s problem, that cost concerns are impeding recovery, that the physician does not have sufficient time to listen and treat, then trust and faith in the physician diminishes. Most physicians still believe that their primary responsibility is to the patient rather than to society in general or to managed care plans. This is a fundamental difference in approach: the one-to-one relationship between patient and physician rather than the one-to-one relationship between physician and society, the latter reflecting the position of managed care. This basic conflict is between medical ethics and medical economics, and this conflict has had disturbing consequences for the physician’s concept of his or her ethical responsibilities. Many physicians can accept limiting therapy for terminal patients. Most physicians cannot accept that medical economics may dictate limiting expensive therapy when that therapy may save a patient’s life. Certainly, in this case, most physicians and patients are in agreement. We must work together. We are patient advocates; we need the patients to be physician advocates.
Despite all of the moral justifications that the primary responsibility of the physician is to the individual patient, I cannot help but agree with Governor Lamm of Colorado (4), who stated that medicine with indemnity care "had invented the unaffordable and was spending the unsustainable." There must be a limit to the cost of medical services. Managed care has effectively decreased costs primarily by decreasing patient services, which in turn has decreased the physician’s influence and thereby reduced the patient’s trust. The latter affects patient well-being. I realize that physicians must function within a budget, but the budget must be under physician control. Resources must be sufficient to treat treatable diseases.
Benson (5) believes that we must be double agents—agents of both the patient and the health care system. The object would be to provide optimal effective care at reasonable cost. He believes we must have concern for the individual but still believe in the distributive ethic. He states that managed care is not designed to deal with important social responsibilities; individuals practicing within managed care rarely provide charity care as part of their practice.
Although managed care may have reduced the cost of medical care, it certainly has not addressed the problems of 45 million uninsured individuals. This is not social justice. Individuals not covered by a managed care plan require government subsidies to obtain health insurance, subsidies which are not currently available. With the abundance of plans offered to individuals and the for-profit motivation of health care executives, health care coverage has become a commodity rather than a social privilege.
As pointed out by Hall and Berenson (6), ethicists recommend that all physicians receive salaried compensation, which would be economically incentive neutral. Managed care executives tend to reject this approach, because salary does not provide the physician with the financial incentive to restrict resources; they want the physician’s income to be affected by his actions. In previous years, physicians could increase their income by means of excessive use of resources. Now managed care wants to increase income to those physicians who use fewer resources, a concept fraught with ethical dangers. Managed care wants to restrict resources by implementing regulations and screening resource use, which, in effect, is rationing. In response to complaints regarding rationing of resources, many health maintenance organizations (HMOs) have offered "focused care" (7), where the consumer can purchase the desired level of care (increased resources), which might include the ability to see physicians outside of the plan, obtain second opinions, and increase pharmacy coverage. Copayments may be required for consumers who opt for more sophisticated plans. However, the main base of HMO support is corporate, and many of the corporate subscribers have little choice about the kind of insurance they receive.
Rationing is not new in medical practice. Physicians have always made decisions about the use of resources on the basis of the clinical condition of the patient, the demands on the physician’s time, and the available personnel and facilities in their given area. What is new is that decisions on the use of resources are now made by others, not by the treating physician. Hall and Berenson (6) state that the primary goal of role-based medical ethics should be the preservation of patient trust in physicians. This is important because trust has a therapeutic role, as well as a moral role. Patient trust is most important when patients are most vulnerable, when they have a serious illness.
I believe, as a physician, that rationing may be necessary to reduce health costs, but this should be under the control of the treating physician. Without guidelines, however, control would be impossible, and guidelines are difficult to establish. The best gauge of the effectiveness of care is the desired outcome. Theoretically, the physician whose patients have the desired outcome is providing the best quality of care. Using first the measure of quality, we would then rank the cost of care for the desired effect on the given disease. Jencks (8) reviewed mortality rates after coronary arterial bypass-graft surgery in the state of New York and the effect of this information on the marketplace. He noted that the majority of cardiologists did not change their referral practices because of this information. Moreover, there was a statistically significant tendency for managed care firms in New York to use centers with higher mortality rates. He speculates that "value purchasing"—in other words, costs—may be the major factor. In Pennsylvania, Schneider and Epstein (9,10) found that publications on the outcomes of cardiac surgery had no discernible effect on patient choices. Patients seem to rank quality of service far behind convenience, access, and costs when choosing health care services.
I do not believe this is shocking information for most readers. The majority of patients are probably influenced in their choices by friends, family, personal physicians, access, and convenience more than by quality. What is frightening in this information is that the implication that there is no need for managed care to increase patient costs by using hospitals and physicians with records of better outcomes. If this is true, then there will be a role for government to establish regulations to reward or sanction health care organizations on the basis of outcomes.
Recently, there have been a few articles related to physicians using deception (ie, lying) to ensure that their patients receive services that they believe are required. Novack et al (11), in a survey of physicians in the Northeast, found that 70% of respondents were willing to document screening tests as a diagnostic necessity to ensure coverage for that service. In a more recent article, Freeman et al (12) presented six vignettes of patient histories in different regions of the United States in which the third-party payer was deceived by the physician in an effort to secure treatment for a patient. They presented these vignettes to 602 randomly selected internists and received 471 responses. Over 50% of the respondents rated the use of deception as justified for patients requiring procedures, such as coronary bypass surgery or arterial revascularization, for any life-threatening condition, but such procedures were often denied by their carriers. The practice of deception to obtain a psychiatric referral or a mammography referral was approved by over 30% of respondents. The use of deception was related to the physician’s belief that their primary responsibility was to be the patient’s advocate, preferably within the rules of the third-party payers; however, if those rules compromised their patient’s care, deception was warranted.
Bloche (13) pointed out that it is difficult to reconcile our public and our deeply personal expectations of medicine. There is an inevitability of conflict between the social purposes of medicine and the ideal of clinical fidelity to the patient. He pointed out that physicians have always incorporated into their practice public health concerns, which sometimes sacrifice the patient’s individual interests to advance community-wide ends. He used vaccination as an example. In many cases today, the adverse effects of a vaccination are much greater than the danger of contracting the disease, but we still vaccinate for social purposes. He believes that we must recognize the ethical value of clinical work on behalf of socially desirable ends and that the exclusive devotion of the physician to the individual patient is an outmoded concept.
There is a special problem that new social trends have created for academic medical centers. Pellegrino (14) discussed the delicate balance between the core mission of academic centers and their need to be responsive to social trends. He stated, "Academic health centers, which combine university medical schools and hospitals, exist to satisfy universal human needs and therefore by definition are instruments of social purpose. ... [S]ociety and academic health centers have mutual obligations. Obligations of society include giving academic health centers financial and other support and allowing them sufficient freedom to pursue their mission; obligations of academic medical centers include accepting greater scrutiny by society and providing social criticism on matters relating to health."
Pellegrino (14) implies that this delicate balance was upset when managed care became a commercial enterprise trying to control and limit clinical decisions for economic purposes. Once it became apparent that it was impossible to restrict demand for health care, the efforts of managed care became concentrated on limiting the supply of health care. Managed care contracts do not recognize any obligation related to education, research, or the care of uninsured individuals. Pellegrino emphasizes the effect of managed care on the primary functions of the academic center.
Teaching
The need to increase patient volume has led to a sharp decrease in the continuity of teaching. Teaching is frequently hurried because of the need to devote time to reimbursable efforts. Managed care does not provide support for teaching; in many ways, teaching is in direct conflict with the needs of managed care. The scholarly clinician so sought after in previous generations is now frequently considered a liability. Students have lost their role models. Instead of learning the natural history of illness, residents are trained to be gatekeepers. The teacher physician is the keeper of a valuable body of knowledge, knowledge that has been honed by experience over many years. The teacher is responsible for transmitting this information to the next generation of physicians. Managed care makes this very difficult.
Patient Care
Generalists are now becoming marginal specialists, and specialists are becoming marginal generalists. Patients are told to put their trust in the plan and not in the doctor, which leads to distrust of the doctor. Patients do not see doctors as interchangeable the way managed care does. Patients want someone they know and trust. The most severe effects of managed care are seen in those patients who require more of the doctor’s time. These include the chronically ill, the elderly, and the patient in need of psychiatric care.
Although we as physicians must be responsible for community and social health, we must not let this occur at the expense of the individual patient; he or she is our first responsibility. As stated by Benson (5), consumers are individuals who buy managed care plans, but when the consumer becomes sick, he or she is a patient.
With our present system, insurers make decisions by determining what they will pay for. If this power is not limited, the insurers would in effect dictate standards of care. There is an obvious conflict of interest, since insurers gain financially by denying coverage. All involved parties—insurers, consumers, and physicians—are pushing for legislation to define standards of care in their favor. Some compromises will be reached in Congress that will, it is hoped, allow physicians to at least define the standards of care that will be administered by insurers.
The California Public Employees Retirement System (CALPERS) is expected to approve a 9.2% increase in their HMO premiums next year (15). CALPERS is the nation’s second largest purchaser of health care after the federal government. CALPERS administrators are concerned that this premium increase may be used to increase administrator salaries or to boost profits, and they are considering abandoning HMOs and contracting directly with doctors and hospitals. They believe that this would increase the quality of care received by members and save money. This plan has evolved because of the frustration of members with the service received from the HMOs. They are now evaluating the cost of this change and whether this will subject CALPERS to regulatory scrutiny and litigation. The importance of this projected change illustrates an attempt by a major insurer to bypass the middleman, the HMO administration, and deal directly with the providers, the physicians. Whether this is successful or not, it illustrates a potential change in the system of medical care.
Insurers expect physicians to accept what Pellegrino (14) has called their distributive ethic: to provide the greatest good for the largest number of patients within the allotted budget. If physicians agree with this concept, they become agents of the plan rather than advocates of the patient. Kassirer (16) has pointed out that it is impossible to provide optimal care for each patient and for the entire group at the same time. He believes that it is unacceptable to deny or provide minimally acceptable care to some patients so that sufficient funds remain to benefit others within the group. I believe that such decisions cannot ethically be made by physicians; the distributive ethic violates our heritage and our commitment to the public we serve.
Our current health care system must be considered a work in progress. Some patients have no limits on their care, others have limited coverage, and others have no coverage. Such a system is basically flawed. There is no equity, and therefore the system is unethical. What should be budgeted for health care? Where should it rank within our national budget? Was 14% of the gross national product too much to spend for health care? I do not know the answers. The fee-for-service system was too wasteful. The current confusing managed care plans are too restrictive and are without equity. It would seem to me that the public would probably agree that supporting health care should be at the top of the agenda. In my opinion, health care is an entitlement for all individuals.
How is managed care perceived as an efficient and fulfilling method for providing health care to its constituents? In a recent survey by the World Health Organization (17) on the rank of countries and health care, the United States was ranked 37th in the world behind all of Europe and just ahead of Cuba. The United States received a top score for the amount of money spent on health care ($3,700 per person per year) but scored poorly on whether health care is fair and equitable. In the latter context, it was ranked equal to Fiji. Obviously, the World Health Organization believes we should be getting a lot more value for the money spent.
The medical community, which had too little input into the initial aspects of managed care, must have far greater input into the future health care system. I hope that within the next 10 years we divest ourselves of the numerous confusing and conflicting health care plans and accept a single-payer system. We will have to ensure that the new system moderates health care costs, provides universal coverage, allows free choice of providers, and controls the overproduction and poor distribution of specialists. I have previously recommended (7) that the Medicaid and Medicare programs be adapted to provide universal health insurance. The program has been tested and works. Individuals would be allowed to upgrade their health care by paying additional fees, but basic health care would be provided for everyone. With this nirvana, physician confidence and patient trust will be restored. I do not know if this will come to pass, but I am convinced that our current system leaves much to be desired.
REFERENCES
This article has been cited by other articles:
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  R. M. Friedenberg Au Revoir, but Not Goodbye Radiology, August 1, 2004; 232(2): 319 - 323. [Full Text] [PDF]
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R. M. Friedenberg Rationing in Health Care: Changing the Patterns of Health Care Radiology, April 1, 2003; 227(1): 5 - 8. [Full Text] [PDF]
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R. M. Friedenberg Patient-Doctor Relationships Radiology, February 1, 2003; 226(2): 306 - 308. [Full Text] [PDF]
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L. G. Hutchins and R. M. Friedenberg Rediscovering High-Value Patient Care Dr Friedenberg responds: Radiology, June 1, 2001; 219(3): 856 - 856. [Full Text] [PDF]
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