Correspondence

Physicians and Managed Care

N Engl J Med 1995; 332:1173-1174April 27, 1995

Article

To the Editor:

The article by Iglehart (Oct. 27 issue)1 is well organized, comprehensive, and also provocative. Unfortunately, an important issue not discussed is the problem of physicians' legal exposure when third-party payers impose limitations on care. Physicians should pause to consider whether these decisions represent the standard of care in the community. In the landmark case of Wickline2 and subsequently Elsesser,3 the message is clear: “The physician who complies without protest with the limitations imposed by a third payor [sic], when his medical judgment dictates otherwise, cannot avoid his ultimate responsibility for his patient's care.” Thus, there is no special or automatic immunity for the physician who joins a managed-care plan, and this obviously creates a problem. In addition, financial incentives for gatekeepers have generated a class-action lawsuit on the grounds that the Racketeer Influenced and Corrupt Organizations (RICO) Act of 1970 was violated.4

Michael I. Weintraub, M.D.
New York Medical College, Valhalla, NY 10595

4 References

1
Iglehart JK. Physicians and the growth of managed care. N Engl J Med 1994;331:1167-1171
Full Text | Web of Science | Medline

2
Wickline 192 CAL App 3D at 1634, 228 Cal Rptr at 663.

3
Elsesser v. Philadelphia College of Osteopathic Medicine. Philadelphia, Pa. 1992.

4
Teti v. U S Health Care, Inc. No. 88-9808 (ED. Pa., Filed 12/27/88).

To the Editor:

Iglehart ends his article with the thought that players in the health care arena will become increasingly uncomfortable, “but practitioners may well bear a disproportionate share of [the discomfort].” This has to be one of the top contenders for the understatement of the year. Physicians are very uncomfortable, and their discomfort will increase as the pressure for accountability continues to mount. Physicians' resistance to accountability goes back a long way; in the early 1900s, Ernest Codman, a prominent Boston surgeon, was criticized by the Massachusetts Medical Society for proposing accountability. It seems contradictory that at a time when less decision-making authority is given to physicians, they are being held increasingly accountable for the outcomes and costs of care. Managed-care systems attempt to provide the framework within which the physician is held accountable. Accountability to parties other than oneself and one's patients is a concept and practice that physicians must accept in order to lessen their degree of discomfort. All physicians need to accept the challenge of accountability and lead the effort to establish it rather than oppose it, or worse, do nothing.

Eugene V. Helsel, M.D.
Community Care Network, San Diego, CA 92123

To the Editor:

Iglehart's review of the growth of managed care is excellent. He focuses clearly on the potentially self-destructive stance of organized medicine in opposing a Canadian-style single-payer system. The question is not whether more government involvement would be good but, rather, whether it would be better than the alternative, managed care, which is what we already have.

Managed care removes choice on the part of patients. In an editorial in the same issue, Kassirer notes, “The customers of managed-care organizations are not individual patients, but employers whose priorities are not necessarily the same as those of the employees who receive the care.”1 Therefore, managed care creates a conflict of interest for physicians who must try not to “overutilize,” in order to remain on the panels of health maintenance organizations. Managed care allows what used to be called insurance companies to shed their risk and place it squarely on the shoulders of doctors and health care providers while not only controlling the allocation of patients and the flow of money but also taking expenses and profits “off the top.” Finally, in the case of for-profit entities, managed care creates a conflict of interest at the corporate level, since the goal of a for-profit entity is to provide profits for its shareholders. The source of the profits is the pool of money from which health care payments must also come. Obviously, if profits increase, the amount of money available for health care payments must decrease.

Joseph T. Marino, M.D.
6620 Coyle Ave., Carmichael, CA 95608

1 References

1
Kassirer JP. Access to specialty care. N Engl J Med 1994;331:1151-1153
Full Text | Web of Science | Medline

Author/Editor Response

Mr. Iglehart replies:

To the Editor: The comments of all three respondents reflect the chorus of physicians' complaints about the rapid growth of managed care. Many of the complaints are legitimate and understandable, but physicians should recognize that this growth is being most aggressively promoted (and paid for) by American corporations, the ideological brethren of most practitioners on the dangers of centralized government. Corporations are promoting managed care for a variety of reasons, but one overrides the others: the ever-increasing cost of medical care has become an uncontrollable business expense.

Dr. Weintraub is quite right — managed care does pose a problem for physicians in terms of potential legal exposure.1 Many court decisions seem to lag behind the emerging social reality that unless the growth of health care spending is somehow moderated, it will endanger equally or even more legitimate competing claims for our limited resources. This is just one more area where new balances will ultimately be struck. Currently, managed care is the leading model for striking these balances in the health care sphere, and it emphasizes private-sector decision making. If it is going to succeed over the long run, managed care must also emphasize physician–manager partnerships.

As Dr. Helsel correctly points out, managed care does demand a higher level of accountability from physicians than traditional fee-for-service medicine, and he urges physicians to address this challenge. But physicians should also recognize that accountability is a two-way street. Unless managed-care plans are accountable to their customers — the employers and employees who pay the bill — they will soon lose both patients and revenue. Moreover, more than a few physicians, particularly in California, have concluded that they can offer their services directly to employers without an indemnity health insurer or a managed-care plan acting as the middleman, thereby maintaining autonomy. That prospect should force all managed-care plans to recognize, as the best plans already do, that their success depends largely on developing effective partnerships with physicians whose services are valued and whose advice is sought. After all, as Emanuel and Dubler emphasize, the physician–patient relationship is the cornerstone of improved health care.2

John K. Iglehart

2 References

1
Manuel BM. Physician liability: new areas of concern under managed care. Bull Am Coll Surg 1995;80:23-26
Medline

2
Emanuel EJ, Dubler NN. Preserving the physician-patient relationship in the era of managed care. JAMA 1995;273:323-329
CrossRef | Web of Science | Medline

Citing Articles (1)