Correspondence
Barriers to Patients' Rights
N Engl J Med 1996; 335:136-137July 11, 1996
- Article
To the Editor:
We strenuously object to Dr. Levinsky's contention (Feb. 22 issue)1 that “managed-care organizations introduce into the doctor–patient relationship powerful third parties whose economic goal is to limit medical care in order to reduce costs.” This is as misleading as saying, “Physicians practice medicine to make money.” Of course they do. They have families to support and retirements to fund. For a physician, however, long-term success requires that the goal of making money be secondary to that of providing quality care for patients.
Similarly, for health maintenance organizations (HMOs), the dominant goal cannot be to limit medical care in order to reduce costs. Instead, the goal must be to improve the quality of care by both reducing services not associated with improved medical outcomes and increasing the provision of services that do improve outcomes: preventive health care, case management, and disease-management services.
Most fee-for-service health care systems are fragmented and fall short in providing these vital services. Our industry, together with employers, has developed the Healthcare Employer Data and Information Set, which attempts to measure these efforts concretely in order to foster comparison among health plans. We also have organizations, such as the National Committee for Quality Assurance, that rigorously assess HMOs' programs of continuous quality improvement in seven areas, which include members' rights and responsibilities, quality management and improvement, utilization management, and credentialing.
We agree with Levinsky that HMOs introduce powerful third parties into the doctor–patient relationship — organizations that can work with their participating physicians to improve the care their members receive.
1 ReferencesDick Salmon, M.D., Ph.D.
Healthsource Innovative Medical Management, Hooksett, NH 03106Frank Middleton, M.D.
Healthsource South, Charleston, SC 294011
Levinsky NG . Social, institutional, and economic barriers to the exercise of patients' rights. N Engl J Med 1996;334:532-534
Full Text | Web of Science | Medline
To the Editor:
I agree with Levinsky that economic barriers to health care due to lack of insurance or to managed care are disgraceful and should be combatted by physicians and the public. I fail to see, however, how information on a physician's malpractice history, surgical mortality rates, or medical history represents a barrier to patients' rights. The practice of medicine is already being scrutinized very strictly in this country by a number of accredited bodies that establish the qualifications of each physician to practice medicine safely and efficiently. I do not believe a patient has any right to know my personal history, any more than I have the right to know the personal history of every airline pilot who flies me around or every cook or waiter who feeds me in a restaurant. Physicians and health care providers have rights, too.
Lodovico Balducci, M.D.
University of South Florida College of Medicine, Tampa, FL 33612To the Editor:
Levinsky confuses the principle of autonomy with the contemporary problem of defining entitlements, specifically in relation to the financing of health care. Autonomy refers to the right to self-governance or self-determination, free from coercion. It does not imply the right to demand goods and services, free from insurance coverage or the ability to pay. Levinsky suggests that autonomy is limited by the absence of third-party payments for certain services. Exactly the opposite is true — that is, autonomy is limited because a third party is responsible for payment. For example, the right to ride a motorcycle without a helmet has been limited in most states, largely because of the argument that the rider will not bear the financial costs of any injury that might occur.
Steve G. Peters, M.D.
Mayo Clinic, Rochester, MN 55905Author/Editor Response
Dr. Levinsky replies:
To the Editor: Drs. Salmon and Middleton deny that the economic goal of managed-care organizations of reducing costs can represent a barrier to the exercise of patients' rights. A growing body of literature (for example, the articles I cited by Weston and Lauria1 and Woolhandler and Himmelstein2) documents the many ways in which patient autonomy is, in fact, eroded by the practices of some managed-care organizations. I agree with Drs. Salmon and Middleton that there are HMOs that make quality and access to appropriate care dominant goals and thus do not constitute barriers to patients' rights.
I disagree with Dr. Balducci's view that scrutiny by accrediting bodies is an adequate substitute for making certain types of information available to members of the public about their doctors. Patient autonomy in the choice of doctors cannot be exercised meaningfully if patients are denied information that would influence that choice.
Dr. Peters states that I have confused autonomy with entitlement to care. My article gives examples to illustrate my point that limiting access to care with economic barriers can undermine patients' autonomy. Although I do believe that just societies should provide universal entitlement to medical care, this issue was not addressed in my article.
2 ReferencesNorman G. Levinsky, M.D.
Boston University Medical Center, Boston, MA 021181
Weston B ,Lauria M . Patient advocacy in the 1990s. N Engl J Med 1996;334:543-544
Full Text | Web of Science | Medline2
Woolhandler S ,Himmelstein DU . Extreme risk -- the new corporate proposition for physicians. N Engl J Med 1995;333:1706-1708
Full Text | Web of Science | Medline
