Correspondence
Managed Care
N Engl J Med 1995; 333:1219-1221November 2, 1995
- Article
To the Editor:
You provide such an excellent analysis of the problems resulting from the way managed-care organizations currently function (July 6 issue)1 that I am amazed that you blame this situation on market forces and values in general, as if all markets were the same. The fact is that the marketplace as defined for the managed-care organizations by the statute writers and rule promulgators bears little resemblance to the competitive free market, which has been called the engine of our economic progress. Rather, it is a terribly perverted and distorted market, which has severely limited the free choice of the consumer — the patient — who pays for managed care through payroll deductions or with labor, as part of a contracted benefit package.
The solution? Do not eliminate market forces and values; instead, eliminate the flawed market system that the governments (both state and federal) have imposed on us. Basically, give the patient, usually an employee, more and freer choices. Remove the restrictions that tie employees to their employer-sponsored plans and let them join any plan within a practical geographic area. Limit employers' function to their contributions to the contracted benefit packages. Liberalize the limitations on enrollment periods so that patients can change plans as easily as possible. Allow the insurers greater latitude in writing a variety of plans to attract subscribers. In effect, force managed-care organizations to market their product to the consumer, not the employer.
A market involving freer choice with properly directed competition will help resolve a number of problems. Certainly physicians will have greater influence on health care plans if patients can easily change plans with their doctors. Markets are not immoral, they are unmoral. They function according to the way they are designed. Our best strategy is to reregulate the market so that it helps to fashion the system we want.
1 ReferencesSherman B. Child, M.D.
2315 Newton Ave. S., Minneapolis, MN 55405-24321
Kassirer JP . Managed care and the morality of the marketplace. N Engl J Med 1995;333:50-52
Full Text | Web of Science | Medline
To the Editor:
You should be commended for your realistic description of physician decision making handicapped by the perverse incentives operating in managed care. However, your overall analysis is erroneous. The editorial mischaracterizes the values and fundamental nature of managed care.
Managed care has some of the superficial characteristics of capitalism (businesses run by chief executive officers, investor ownership, and the like). In reality, however, managed care depends on antimarket values. Indeed, a major factor behind the enormously rapid growth of health maintenance organizations (HMOs) is that the government gave corporations a 100 percent tax deduction for dollars used to enroll their employees in — that is, force them to join — managed-care plans.
Consider the context in which managed care originated.1 Before managed care, there were the diagnosis-related groups of Medicare, which, like HMOs, represented an attempt to control costs. Before diagnosis-related groups, there was the old Medicare. The origin of today's mess was the 1965 Medicare legislation. The root cause of our crisis is that government became a dominant player, distorting the “marketplace,” which gradually became a less free marketplace. Government — that is, Medicare — reimbursement became the standard for the insurance companies, thereby distorting the fee-for-service system as well.
Ask any corporate employee railroaded into an HMO whether he or she could freely shop in the health care marketplace. Ask physicians whether they can freely trade their valuable services for a voluntary and rationally negotiated fee from autonomous patients. No wonder there is a growing push for medical savings accounts as one method to empower individual patients and, by extension, their physicians.
We should call managed care what it really is: a statist, collectivist, anti-individualist, antimarket system, masquerading as capitalistic and market-oriented. Consider your statement: “Because individualism and competition are increasingly celebrated, the principles of the marketplace now permeate our personal lives and even capture our judgment.” If only this were true; on the contrary, it is a profound misperception. Unfortunately, we have a sham marketplace, because it is not a free marketplace.
The medical profession and its leaders need to grasp the essential nature of managed care and the immorality of the pseudo-marketplace. Only then will we be able to avert the death of our profession.1
1 ReferencesDavid E. Kim, M.D.
27485 Lost Trail Dr., Laguna Hills, CA 92653To the Editor:
Manipulated by the artful rhetoric of antigovernment, antitax idealogues, the Congress has facilitated an unprecedented deconstruction and degradation of our health system. The process has placed the nation's standards of health in jeopardy.
The realities of rising costs are the cover for this raid by corporate takeover experts. The billions to be harvested from the trillion-dollar health care enterprises are, of course, irresistible to the corporate firms whose function, fundamentally, is to maximize returns to their investors. Their current string of victories required, first of all, the rejection of simple health reform through single-payer national health insurance. This alternative, which has served Canada so well for over two decades, would control costs, accomplish genuine universal access to care, and protect patient choice and physician autonomy, while rendering redundant the army of bureaucratic interveners. As you point out, we are meant to provide care, not restrict it. This simple truism emerges as our battle cry.
Quentin D. Young, M.D.
Physicians for a National Health Program, Chicago, IL 60604To the Editor:
The cogent issues you raise are important factors in the emerging medical marketplace. It is critical to understand that this marketplace has a morality no different from any other; efficiency and price drive the system and lure the buyer. Little else matters to nonphysicians, who increasingly control all aspects of care. Moreover, insurance company executives take no oath whatsoever, and their “morality” is purely profit driven.
While we are held to a higher moral standard than others, it is critically important that medical leadership and prestigious journals reaffirm, actively support, and legitimize our right to insist on and negotiate for fair compensation for our work. Whereas politicians and perhaps even society may have spoken from their perspectives, physicians must vigorously exercise their right to economic security, even to the point of taking civil and legal action.
Rather than meekly accept the gloom, physicians (and primary care physicians, in particular) may wish to band together in economic superunits to influence health care decisions with the only remaining power left to them — the power to refuse to participate in plans that are too oppressive or that pay a demeaning wage. This approach may be the last chance we have to return health care power to physicians and take it away from hospitals, insurers, and politicians.
Sam J. Sugar, M.D.
1800 Sherman Ave., Evanston, IL 60201To the Editor:
Instead of organizing the profession to combat the insurance-dominated system that is denying services and bleeding unconscionable profits from patients, hospitals, and physicians, our leaders seem to be concentrating on preserving their own influence and manipulating the system to benefit their own institutions.
What has set medicine apart from other occupations is the moral authority that stems from its dedication to patient care. The physician has been the patient's advocate and defender. By agreeing to serve the interests of the insurance company, the HMO, or anybody other than the patient, we are giving up the moral high ground — the singleness of motivation that has generated the trust of our patients and society. When we cooperate with managed-care companies and the managed-care agenda, we are reducing ourselves to the level of businesspeople — just doing our job, making a living, doing what we are told. You predict that many physicians “will find themselves conforming to the restrictions and deceiving themselves that what they are doing is best for their patients.” I will find that difficult. I hope that most of my colleagues will as well. It is ultimately individual physicians who must determine what is in the best interest of their patients. The primacy of that responsibility dates back 3000 years, to Hippocrates. It transcends government regulation, war, managed care, and institutional loyalty.
Realistically, however, no single physician or institution can stand up to the juggernaut of managed care. But united, we can and must defeat it. The government, the insurance industry, and the health planners, all of whom are for various reasons antiphysician, have succeeded in fragmenting medicine and pitting one specialty against another. Divided, grasping for a slight advantage over our fellows, quibbling about the relative value of one type of service as compared with another, we have become easy prey. But it is really our patients who have begun to suffer. It is for their sakes, rather than for our own short-term economic advantage, that we are obligated to resist the current, market-driven trends.
How can we band together to achieve our goals and recapture what has been lost? The antitrust laws prohibit us from negotiating in groups and even from discussing joint actions, unless we are “integrated” and “at risk.” The insurance companies, HMOs, and government agencies are under no such strictures. The simplest solution to our problem is legislative relief: we must force change in the antitrust laws and level the playing field. To make a credible demand, physicians must be united, because only a sizable group can have a meaningful impact. Here, our leaders have failed us. It is time for them to put aside divisive issues and concern for individual-specialty advantage. They must take risks in order to unite us, and we as physicians must support them. If we cease to practice primarily for the benefit of patients and instead act only to preserve our economic skins, we will quickly lose society's trust and our own legitimacy.
Randall J. Lewis, M.D.
2021 K St., Suite 400, Washington, DC 20006To the Editor:
You fail to mention the recent malignant transformation wherein the most profitable companies (those that spend the least for medical care?) buy out the others. As I understand it, a company's profitability determines its stock price. With a high stock price, the company can then finance acquisitions of other managed-care entities, so that in short order it controls various markets. Even if the companies are not monopolistic, those companies that will dominate the medical marketplace will be the most profitable ones. The analogy to cancer is striking: the out-of-control, aggressive cells overwhelm the normal ones, with dire consequences for the host. The only good thing about all this is that the inevitable end-stage scandal will arrive relatively quickly because of the buy-out frenzy. I predict, in relatively few years, a public outcry, congressional hearings, and resultant legislation. Profits from corporate health care will eventually be regulated, as are those of public-utility companies. Sadly, the remedy will arrive too late for many patients. Our health care is already, or soon to become, cheap, not very good, but increasingly profitable.
Jay M. Pomerantz, M.D.
123 Dwight Rd., Longmeadow, MA 01106To the Editor:
My hat is off to you. Your editorial “Managed Care and the Morality of the Marketplace” marks your coming of age as the editor of our front-rank journal. Perhaps someday its publication will be marked as a turning point in the tide of medical reform, although experienced observers will want to postpone breath-holding for the moment. Your sentiments draw the line in the sand we must all acknowledge lest we be dragged across, unwittingly and too late to resist. I would add only that you stop short of telling the truth about one of the fundamental antecedents to the current dilemma: physicians have been strangling the goose that lays the golden eggs for all it is worth for years. The insidious self-deceptions that you correctly predict will become widespread under capitated plans to justify withholding care have already been honed to a fine edge in the opposite direction. An example from my own specialty is the routine administration of combination chemotherapy to patients with metastatic non–small-cell lung cancer, regardless of performance status, often followed by second- and third-line therapies when the first proves ineffective. It is neither easy nor financially rewarding (in a fee-for-service setting) to explain to a dying patient that your treatment holds only false hope or worse, just as it is neither easy nor financially rewarding (in a capitated setting) to order magnetic resonance imaging for a patient with metastatic cancer and back pain if it may push your “asset utilization rating” over the top and result in contract nonrenewal. The solution is no clearer to me than anyone else, but I believe we must start by recognizing our role in bringing ourselves to the present state of affairs. I applaud your splendid effort to clarify that state of affairs.
Fred Millard, M.D.
3314 Hawthorn St., San Diego, CA 92104Author/Editor Response
Editor's reply:
These letters speak for themselves. None of them, nor the dozens of others I received in response to my editorial, found fault with the fundamental message — namely, that the machinations of the marketplace (which, admittedly, is not classical) are creating problems of enormous proportions for patients, physicians, hospitals, medical schools, and medical research. I do not doubt that the corporatization of health care will be with us for many years. Although some in industry liken the practice of medicine to a tidy production line,1 medicine is no ordinary business. Patients are not standardized widgets, diagnostic tests are imperfect, treatment regimens are not invariably uniform, and medical science and practice are quite properly in a continuous and sometimes rapid state of evolution. Physicians are humans with human frailties, not automatons.
Managed care has much to offer with respect to efficiency in the delivery of health services, yet with respect to the common purposes of research, education, and community service, it has so far offered little. Making money in a health care business is not a sufficient goal; for-profit companies must become worthy citizens as well as worthy investments. The diversion of health care dollars into unparalleled executive compensations, hefty stockholder profits, and massive corporate reserves is not my idea of good citizenship.
1 ReferencesJerome P. Kassirer, M.D.
