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Perspectives |
1 From the Department of Radiological Sciences, University of California, Irvine Medical Center, Orange. Received July 31, 2000; accepted August 4. Address correspondence to the author, 18961 Castlegate Ln, Santa Ana, CA 92705 (e-mail: rmfriede@uci.edu).
Index terms: Perspectives • Radiology and radiologists, socioeconomic issues
This past June, the United States Supreme Court, in blunt language, defined the purpose of managed health care (1). The Court’s comments were made in their brief concerning Pegram v Herdrich, a case where a woman’s appendix ruptured while she had to wait 8 days to undergo diagnostic tests for abdominal pain. She sued, complaining that her health maintenance organization (HMO) provider improperly restricted her access to diagnostic procedures. The Court decided in favor of the HMO, stating that rationing health care is intrinsic to the design and mission of HMOs. As reported by the Orange County Register (1), Justice Souter, writing for the unanimous decision, stated, "No HMO organization could survive without some incentive connecting physician reward with treatment rationing... [T]here must be rationing and inducement to ration care." What was previously talked about furtively is now openly stated: Cost-effectiveness and the profit incentive call for rationing of care, and this goes to the very heart of any HMO scheme. Justice Souter treated rationing as a fact of life and said the Congress should distinguish between good and bad rationing. Gregg Bloche, professor at Georgetown University Law Center in Washington, DC, believes that Justice Souter knew exactly what he was doing. He said that the Court was saying to the American people, "Wake up. Health plans are holding down costs by denying beneficial care. The essence of the HMO concept is rationing" (1). It appears that many HMOs were embarrassed by the blunt statements. Allen Bloom, senior vice-president of Maxicare Health Plans, said, "The Court did not understand the use of the word rationing. It’s an unfortunate word which implies that needed care is being cut back. I’d call it...medically appropriate care" (1).
Rationing of medical care has been going on for decades. Rationing occurs when the physician decreases time spent with a patient, when decisions are made on withholding life support in terminal cases, and with regard to the availability of specialized equipment and specialized physicians. The difference is that rationing in the past occurred either because of the unavailability of physicians or equipment or in conjunction with the decisions of the immediate family. With the soaring costs of medical care, most informed individuals agree that rationing must increase, but the questions are who is to make the decisions and how will it be regulated. Rationing by managed care organizations is an effort to provide the maximum benefits of health care with a limited budget.
To maximize savings, managed care has added new forms of rationing: rationing by delay, rationing by denial, and rationing by dilution (2). Rationing by dilution leads to the concept of distributive justice: the selection of which patients should receive treatment and which should not when resources are limited. There are other forms of rationing that lead to questions of social justice. Should we ration by age? The elderly have lived through all phases of life, the young have not. If we have two patients, one 35 years of age and one 70 years of age, should limited resources be channeled to the 35-year-old patient and perhaps sacrifice the 70-year-old patient? Veatch (3) proposes that the priority of health care be inversely proportional to age because older people have had the opportunity to live longer and younger people have lived less of their lives. Should persons who have endangered their own health, such as smokers, receive fewer resources? Should individuals who are socially or economically valued by society receive preference over the unemployed? This list could go on; once rationing is acceptable as a tool to control resources, the possibilities are endless. There is a need for rationing, but it must not be arbitrary. Rationing must be controlled and regulated.
When medical care is rationed, the greatest danger is that the overall quality of care will suffer. Managed care organizations have expressed the need to measure quality of care to ensure that resources are being utilized properly. In most cases, an internal committee of managers and physicians try to evaluate and maintain quality. There are certain easy measurements related to quality that can be obtained: What percentage of women over the age of 40 years undergo mammography and Pap (Papanicolaou) tests? How effective is the vaccination program? How does the surgical outcome compare with accepted norms? When we rely on statistical measurements, "quality" can be determined easily by managed care executives, who often are not physicians. Although the number of screening examinations are easy to calculate, not all screening examinations have the same value. It has been estimated that the use of Pap tests to screen women for cervical carcinoma costs $1 million per life saved, while the use of occult blood tests to screen people for colon cancer costs $26 million per life saved (4).
Managed care organizations may receive plaudits for emphasizing preventive medicine, but this may not always be an efficient use of limited resources. The National Committee for Quality Assurance, which grants accreditation to HMOs, has suggested four major areas for performance standards: quality, access and patient satisfaction, membership and utilization, and chronic care (5). Most of these measures involve preventive medicine and chronic care. There are few specifics regarding quality of and access to acute care, which is much more subjective and difficult to measure. The bottom line is that we still are not able to measure overall quality of care.
Health care in the United States is inequitable, bureaucratized, and expensive. In most health care systems except that in the United States, basic health care is available to everyone. Loewy (6) stated that we have an overwhelming advantage in that we are so far behind other countries in creating an equitable and fair system that we can learn from and include in our system that which is good in other systems. He believes that one reason for our lack of an equitable system is that those who created our system are affluent individuals who can afford private insurance and that these same individuals would have to bear the tax burden to insure those who are less well off. We are perhaps the only major country that treats health care as a purchasable commodity and not as a basic individual right. Health care should be a national responsibility and requires responsible stewardship. In no other enterprise is morality so closely associated with the bottom line.
The American Medical Association reported (7) in 1996 that physicians identified access as the most pressing issue in medicine. Are we entitled to second-guess a patient’s interpretation of illness? When a patient considers himself or herself ill, is the patient not entitled to be examined by a physician promptly? If a physician needs tests and consultations to exclude significant differential diagnoses, should this not be allowed? At what level should we draw the line? We cannot afford to establish rules specifying when a patient can see a physician. Illness is very personal, and the decision on the need for medical attention must be each individual’s decision.
There has been considerable emphasis on the physician’s use of clinical practice guidelines, which certainly may assist a physician as a helpful adjunct. At their best, guidelines express the noblest aims of medicine’s search for the best way to serve patients. At their worst, they can be a straitjacket of outdated recipes reinforced by individuals without clinical expertise (5). Guidelines work best when there is symmetry in the presentation of diseases. Unfortunately, variable presentations are all too common, such that presentation and differential diagnosis vary from patient to patient with the same disease. Under such circumstances, guidelines are less valuable and may be misleading. Guidelines must be flexible in the hands of the treating physician.
Agich (8) stated that medical care under managed care is a social process delivered in many settings and relationships aside from the patient-physician relationship. In managed care, the central care provider may be the managed care organization and not the physician. Agich believes that with managed care offering continuity of care through screening and preventive services, the organization has replaced the physician as the main provider. Whether the patient will accept the change from a physician-patient relationship to a managed care–patient relationship remains to be seen. Agich pointed out that the original physician-patient relationship existing in the early 20th century changed drastically with the technologic revolution of the 1960s and 1970s. Now the clinical diagnosis is not provided by the patient or by the physician but is obtained by means of laboratory test or radiologic results or after consultation with specialists. The physician-patient relationship then becomes a series of relationships. The increased complexity of the relationships was actually the beginning of managed care but was not cost-efficient managed care. Physicians were not concerned with controlling costs, which provided the beachhead for managed care executives to take over the management of medical care. The loss of the physician-patient relationship led to increasing public distrust of physicians, concern that physicians were not primarily concerned with the patient’s best interests, and a breach in patient trust and support of physicians. This further opened the way to executive management control of medical care. The gatekeeper became the physician representative on the HMO team for physician-management patient care.
Rationing is primarily a patient concern. Although patients are not necessarily knowledgeable, as the ones most concerned they must be consulted when rationing of medical care is considered. The extent of rationing is partially dependent on the percentage of the gross national product allocated to health care. The percentage of the gross national product allocated to health care is really the decision of the public, who pay for it and who are served by the system. A substantial amount of health care costs are expended in the last few months of life. If rationing were to be applied to terminal care, substantial savings would result. When healthy, many individuals make the decision not to be maintained with life-sustaining devices. However, these same individuals when ill—even when terminally ill—do not desire death. Study results (9) have shown that most patients were willing to accept intensive chemotherapy for a very small chance of benefit, even if it meant more pain and discomfort. When healthy individuals state that if they have a terminal disease they would rather die than undergo extreme measures to prolong life, when faced with that fact they frequently elect to prolong life. We know that it is difficult to predict in any given terminally ill patient the true time of death. In one example (9), 70% of patients identified as being terminally ill (fewer than 6 months to live) were still alive at 6 months, while 58% of patients not considered to be terminally ill died within that interval. It is unlikely that the public would be willing to ration terminal medical care even if the outcome would be death.
Loewy (6) stated that the system in the United States is the product of a society in which individualism reigns supreme. He believes that the system is not necessarily geared to using resources to optimize equitable care but is geared to conserve resources to maximize the pay of managers and the profits of stockholders. The rules of the HMO and the pressures on the physician gatekeeper may be to provide too little service, which is more unethical than the provision of too much service in the fee-for-service era.
The Medical Council of New Zealand issued ethical guidelines for doctors involved in organizations that control limited resources (10). Most of the guidelines state basic moral and ethical principles of the patient-physician relationship and the necessary independence of medical action from financial gain. However, within their summary, the council made several important statements, four of which are quoted below (10):
1. "Doctors cannot be held responsible in any form for not providing what is not in their power to provide."
2. "Where the best method of diagnosis or treatment can be identified but cannot be provided, doctors are advised to explain to the patient what is optimal and what is available and the consequences of taking the available course of action. The discussion should be documented."
3. "That where the state or agency of the state or an institution decides upon the services to be made available to the public, the responsibility for the consequences for those decisions must largely rest with the state or the institution as the case may be."
4. "Doctors who have been made to provide a service which they deem suboptimal must still inform the patient of the optimal care and must furthermore advocate for its provision."
Managed care as we practice it today is in a state of transition. The plethora of managed care organizations and the variables among organizations are leading to an unworkable and unnecessarily complex system for delivery of health care. As managed care progresses, I hope that we will wind up with either a federally sponsored plan or at least a consolidated private carrier plan. Health care may be offered as a single- or multiple-tiered system (6). In a single-tiered system, everyone has access to the same care and services and cannot purchase more. In a multiple-tiered system, everyone is provided with a basic minimum, and additional options and services can be purchased by the individual. The United States currently is experimenting with both methods, but our history is such that a multiple-tiered system will almost certainly prevail.
Health care is expensive and will remain expensive in the future. In addition, there is the moral imperative that we must cover basic health care costs for the 42 million individuals currently without health care coverage. We must regulate hospital costs, physician services, and, to some degree, patient expectations. Health care is not a commodity. All individuals should be entitled to health care even when they cannot afford it. One of the difficulties with the multiple types of plans and companies now engaged in health care is that consumers generally do not understand what is good health care and what is a fair price. If they make a mistake in the selection of a plan, their choice may be fatal.
The concept of rationing by access, delay, and denial frightens me. There are so many unpredictable variables involved (as in the case of the woman’s burst appendix) that we do not have the wisdom to solve. Rationing by stated principles of care would be easier, such as rationing for incurable conditions where the quality of life is poor, prohibiting treatment to prolong life, or prohibiting treatment of children with severe congenital disabilities that will prevent a productive life. In those areas alone, substantial savings could be accomplished, but the concepts would almost certainly not be acceptable to the public. I would not want to be a member of a committee forced to make such decisions.
What I have presented to you is that rationing may be necessary but is extremely difficult and often borders on the immoral. How should rationing be approached? We would like to be ethical, fair, and efficient. Ethical and fair are subjective terms that are difficult to define. Certainly, if every managed care organization sets up its own rationing system, we will have many definitions of ethical and fair. The quality-adjusted life year, or QALY, is supposed to be a measure of the number of years of a standard quality of life that can be expected as a result of a given treatment. If this is used as one of the decision measurements for access to care, we are then assessing the benefit from care and discriminating against the urgent need for care (2).
I believe that we should regulate rationing on a national basis, where all managed care organizations would be required to adopt the same standards. Principles for consideration might include age, curability, quality of life, and productivity—items that I am sure each managed care organization includes today in some manner for their own decisions. This can be regulated and enforced. Is it fair? No. Individuals with unlimited finances can always purchase what care they need. But within the concept of a basic health care plan, it at least provides an even playing field for all.
Most physicians agree that the current managed care system is defective, with financial and ethical problems. By establishing federal standards on how rationing will be accomplished by managed care organizations, we will be dictating rules of access and regulating denial of care. With control of rationing, we will have a second chance as health care professionals to modify the system for the patient’s benefit. Our major societies should seize this opportunity.
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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 I. Imaoka, A. Wada, M. Matsuo, M. Yoshida, H. Kitagaki, and K. Sugimura MR Imaging of Disorders Associated with Female Infertility: Use in Diagnosis, Treatment, and Management RadioGraphics, November 1, 2003; 23(6): 1401 - 1421. [Abstract] [Full Text] [PDF]
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