Correspondence
Putting Patients First?
N Engl J Med 1997; 337:1084-1086October 9, 1997
- Article
To the Editor:
The editor of the New England Journal of Medicine is entitled to be a critic of managed care, but it is profoundly disturbing to see such an important and presumably dispassionate publication used as a sounding board for these critical views (July 31 issue).1
The managed-care community, acting through the American Association of Health Plans (AAHP), is in the process of developing and implementing the AAHP's Putting Patients First initiative. We were disappointed that in critiquing this program, you gave insufficient attention to what this unprecedented effort does and missed the importance of our members' going on record on key issues of concern to patients and physicians.
Putting Patients First is a work in progress, as AAHP and our member plans have emphasized since launching this initiative eight months ago. During that time, health plans have mounted a proactive program to educate consumer, employer, and provider groups about these policies and practices. Nevertheless, the Journal has now written off Putting Patients First as a public-relations ploy.
These are the key facts, in chronologic order. First, more active and accountable management of care has been widely recognized as a necessity if health care is to remain broadly accessible and affordable in the years ahead. Second, managed care has rapidly replaced fee for service as the nation's preferred approach to health care delivery. Third, this change has generated a backlash among fee-for-service proponents, some of whom have misrepresented how health plans work and continue to publicize alleged failures of care as though they were the rule rather than the exception. Fourth, this backlash has resulted in myriad attempts at the state and federal level to legislate clinical practices — a government-knows-best approach that has never been taught in medical school and that most physicians have always opposed.
What makes AAHP's Putting Patients First unique is that it is the first industrywide attempt to identify and address practices that warrant either greater clarity or greater consistency of application. A commitment of this scope would be rare in any industry and is unprecedented in health care. Given this fact, it is unfortunate that you are unwilling to withhold judgment on Putting Patients First until the initiative has been fully implemented and more returns are in.
1 ReferencesKaren Ignagni, M.B.A.
American Association of Health Plans, Washington, DC 200361
Kassirer JP . Managing managed care's tarnished image. N Engl J Med 1997;337:338-339
Full Text | Web of Science | Medline
To the Editor:
Your condemnation of the AAHP's Putting Patients First initiative represents the same sort of strategic thinking and understanding that have given us an incredibly costly fee-for-service system, zero accountability, no access for millions of Americans, and legislative intrusion into clinical practice. The principles and practices embodied in Putting Patients First will substantially strengthen the health care systems that courageously wrestle with the very real issues of appropriateness, effectiveness, access, affordability, and responsibility. Premature and unfounded criticism is the usual accomplice to the inevitable protest that accompanies change.
Douglas R. Woll, M.D.
SelectCare, Troy, MI 48084To the Editor:
Multiple times you have taken to task that nebulous entity, managed care, most recently castigating the AAHP's initiative, Putting Patients First.
You would have the AAHP make its standards requirements rather than recommendations. I believe you have confused the capabilities of a trade association with those of a regulatory entity. A trade association establishes recommendations (shoulds), not requirements (musts). Regulatory entities determine the requirements (musts) for the health care industry and other industries. . . .
I agree with many of your criticisms of the managed-care industry and managed-care organizations. We need to do better. We, and many other managed-care organizations, strive to do better through accreditation, report cards, and numerous clinical and service quality-improvement projects. Increasingly, in this era of “value purchasing,” the market, if not the regulators, will require these efforts.1
Managed care occurred in response to the desire of purchasers (employers) to rationalize health care. It is a reaction of the marketplace to the health care system that physicians helped create. Managed care is a work in progress. It will better serve all if doctors actively contribute to the shaping of this work in progress.
1 ReferencesNicholas E. Mischler, M.D.
Wausau Insurance Companies, Wausau, WI 54401-8076To the Editor:
I would like to respond to one of your complaints in your editorial. When was the last time that non–managed-care physicians disclosed their strong financial incentives to perform unnecessary and even inappropriate — but lucrative — procedures?
. . . The problems in managed care are mirrored by abuses in the fee-for-service sector. Until this is openly acknowledged, the national debate will continue to be biased, vitriolic, and unproductive.
Daniel Temianka, M.D.
HealthCare Partners Medical Group, Los Angeles, CA 90015To the Editor:
Is it just me or are other physicians upset about your many diatribes against managed care? As I understand your core position, you are vehemently opposed to for-profit medicine. What is traditional fee-for-service medicine but for-profit medicine that gilds the pockets of physicians, pharmaceutical companies, and hospitals? The fee-for-service system of medicine that is being dismantled has done nothing to support medical schools and research that we all agree must go on. A possible solution for this problem is a “research tax” on all practicing physicians in the United States, most of whom have six-figure incomes.
Maintaining a system of fee-for-service care that has failed to control health care costs and has allowed solo practitioners to practice with little or no peer review should not be indirectly condoned by an influential physician like you, Dr. Kassirer, with your constant breast beating about the evils of managed care.
Yes, managed care is an imperfect system of health care, but it is better than the alternative. . . . Those of us who have been laboring in the field of managed care or government-sponsored medicine are for the most part doing good and noble jobs. We are paid for our work. We even make a profit or receive salary increases if we control costs. This is not evil, as you indirectly suggest.
The Roman Empire of fee-for-service medicine is collapsing. Its best element, personal care provided by a physician the patient knows, will be retained by health maintenance organizations (HMOs) that want to survive in a competitive market. Dr. Kassirer, could you change the subject or allow other opinions to surface in this debate?
Steven Snyder, M.D.
1803 Laguna St., San Francisco, CA 94115To the Editor:
Although the AAHP and some of its members may condemn you for your editorial, I am happy to inform you that I am not one of them. I believe your editorial was on target.
At our health service, we have always put patients first, and we will continue to do so. Our physicians treat patients the same as they would treat their private patients, because in essence, these patients are their private patients once our physicians assume responsibility for their care. Fundamental to this concept is the fact that our physicians are not limited by capitation. They are free to order any test or procedure they deem necessary for the care of their patients. There is no second-guessing of the physicians, although I sometimes discuss a request for a test with a physician if it appears that a different test (in many cases, one that is more costly than the test requested) may be more appropriate for the problem being evaluated.
Our health service is a nonprofit medical center that began in 1955 as a group practice, and although it has also been licensed as an HMO, we continue to operate as a group practice. We are a staff-model HMO with an extremely low turnover of physicians and few complaints by patients. At present, we provide services to about 30,000 enrollees, many of whom are in a low-income bracket. Our physicians and other members of the professional staff contribute immensely to the maintenance of our solvency. They could all earn more in a for-profit HMO or managed-care plan, but they prefer to stay with us to practice freely and with a feeling of dignity as professionals.
I want to lend my support to the Journal in letting the AAHP and all managed-care organizations know that they are being closely watched and that only excellent outcomes will demonstrate that they really are putting patients first. The huge amounts of money expended for health care need to be directed more to the needs of patients and not to investments that enrich the already enriched insuring agents.
Angelo P. Creticos, M.D.
Union Health Service, Chicago, IL 60612Author/Editor Response
Dr. Kassirer replies:
In my editorial I acknowledged that “Putting Patients First may be a laudable start at setting industry norms,” but I argued that the program lacks both strong standards and rigorous compliance procedures. The letter from the AAHP discusses some historical background, but it does not address these criticisms. So far, the industry has been unwilling to raise standards or develop an external, independent mechanism to expel members who fail to comply with such standards. This led me to conclude that the program is “little more than a thinly veiled attempt to ward off state and federal legislative actions to curb the abuses of managed care.” I was not the first or the only commentator who came to this conclusion about several public initiatives of the AAHP. 1-5
In response to the accusation by Drs. Mischler and Snyder that I have carped repeatedly about the practices of managed care, I plead guilty. At different times over the past three years, I have been critical of multiple abuses, including gag rules,6 the gatekeeper model,7 the restriction of specialty care,8 cherry picking,9 the perverse financial incentives of capitated arrangements,10 the profit motive in health care,11 and the treatment of medical care as just another commodity in the marketplace.6 Drs. Mischler, Snyder, and Temianka fail to point to my several criticisms of the fee-for-service system6,8 and my acknowledgment of the many benefits of managed care.6,7 The writers seem to imply that I have been single-minded, only criticizing managed care. In fact, I believe I have been an “equal opportunity” critic: of physicians for financial conflicts of interest,12 of medical leaders for failing to speak out on critical issues,6,10,13 of Congress for intruding itself into medical care,14 of the Federal Council for Internal Medicine,15 of the American Medical Association,16-18 of the gun lobby,19,20 and of the director of the Office of Drug Control Policy, the attorney general, the secretary of health and human services, and the President of the United States.21
Dr. Mischler makes an error in logic. If trade associations are supposed to set lofty ideals, why does the AAHP also tout its enforcement mechanism? And how, Dr. Woll, could weak standards be expected to strengthen any of managed care's practices?
Dr. Snyder is wrong about the support of research and education in the fee-for-service system. Third-party payers paid a premium to academic medical centers for their care, and part of these funds supported the hospitals' and schools' academic goals. During the same time, academic departments in medical centers supported their faculty to carry out research and supported the medical schools — sometimes handsomely — with a “dean's tax.” Dr. Snyder proposes a tax on rich physicians; I proposed a tax on the rich insurance companies.9,22 Finally, Dr. Creticos's comments speak for themselves.
22 ReferencesJerome P. Kassirer, M.D.
1
Rich S. HMO group's policy seeks to reduce fears. Boston Globe. December 18, 1996:C14.
2
Kertesz L. AAHP campaign urges HMOs to open up. Modern Healthcare. December 23, 1996:11.
3
Conklin M. Health group vows consumer kindness: association pledges to monitor members to cut complaints but won't disclose details. Rocky Mountain News. April 23, 1997:9B.
4
Pear R. H.M.O.'s fight plan to pay for some emergency care. New York Times. June 25, 1997:A16.
5
Kertesz L. HMO makeover: are managed care's efforts to overhaul its image too little, too late? Modern Healthcare. May 12, 1997:36-8, 42, 44, 46.
6
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Full Text | Web of Science | Medline7
Kassirer JP . Is managed care here to stay? N Engl J Med 1997;336:1013-1014
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Kassirer JP . Access to specialty care. N Engl J Med 1994;331:1151-1153
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Kassirer JP . Academic medical centers under siege. N Engl J Med 1994;331:1370-1371
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Kassirer JP . Our endangered integrity -- it can only get worse. N Engl J Med 1997;336:1666-1667
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Kassirer JP . The new health care game. N Engl J Med 1996;335:433-433
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Kassirer JP . Medicine at center stage. N Engl J Med 1993;328:1268-1269
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Kassirer JP . Firearms and the killing threshold. N Engl J Med 1991;325:1647-1650
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Kassirer JP . Practicing medicine without a license -- the new intrusions by Congress. N Engl J Med 1997;336:1747-1747
Full Text | Web of Science | Medline15
Kassirer JP . Primary care and the affliction of internal medicine. N Engl J Med 1993;328:648-651
Full Text | Web of Science | Medline16
Kassirer JP . The new surrogates for board certification -- what should the standards be? N Engl J Med 1997;337:43-44
Full Text | Web of Science | Medline17
Kassirer JP . Managing managed care's tarnished image. N Engl J Med 1997;337:338-339
Full Text | Web of Science | Medline18
Kassirer JP ,Angell M . The high price of product endorsement. N Engl J Med 1997;337:700-700
Full Text | Web of Science | Medline19
Kassirer JP . Guns in the household. N Engl J Med 1993;329:1117-1119
Full Text | Web of Science | Medline20
Kassirer JP . A partisan assault on science -- the threat to the CDC. N Engl J Med 1995;333:793-794
Full Text | Web of Science | Medline21
Kassirer JP . Federal foolishness and marijuana. N Engl J Med 1997;336:366-367
Full Text | Web of Science | Medline22
Kassirer JP . Tribulations and rewards of academic medicine -- where does teaching fit? N Engl J Med 1996;334:184-185
Full Text | Web of Science | Medline
- Citing Articles (1)
Citing Articles
1
(1998) Professionalism. New England Journal of Medicine 338:1, 66-66
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- Letters
