Correspondence
Views of Managed Care
N Engl J Med 1999; 341:616-618August 19, 1999
- Article
To the Editor:
Seven of the nine authors of the survey by Simon et al. on views of managed care (March 25 issue)1 are affiliated with Harvard Pilgrim Health Care, according to the identifying information on the first page of the article. Readers not familiar with health care delivery in New England may not realize that Harvard Pilgrim is a large managed-care organization and not a department of Harvard Medical School. Perhaps this affiliation qualifies as a potential conflict of interest that should have been disclosed even more clearly.
Although the quality of the research appears to be excellent, the authors' discussion seems to minimize the extraordinary seriousness of the respondents' criticisms of managed care and seems to imply that medical educators are failing to teach students properly about managed care. An alternative perspective, voiced persuasively by Michels in his editorial, is that medical education is working well to foster “healthy skepticism” about managed care.2 Moreover, Simon et al. devote only a single sentence of their discussion to the striking finding that approximately 57 percent of respondents favored a single-payer system (as compared with 22 percent who favored managed care and 19 percent who favored a fee-for-service system).
Although the authors are certainly entitled to slant the discussion according to their views, more background information would have helped readers understand a potentially important influence on the authors' perspective.
2 ReferencesAllen S. Brett, M.D.
University of South Carolina School of Medicine, Columbia, SC 292031
Simon SR ,Pan RJD ,Sullivan AM , et al. Views of managed care -- a survey of students, residents, faculty, and deans at medical schools in the United States. N Engl J Med 1999;340:928-936
Full Text | Web of Science | Medline2
Michels R . Medical education and managed care. N Engl J Med 1999;340:959-961
Full Text | Web of Science | Medline
To the Editor:
That managed care is perceived negatively by medical students, residents, faculty members, and academic deans is hardly surprising, considering the current backlash of resentment among members of the public and the medical profession. Since Simon et al. did not define “managed care” for their respondents, they were vulnerable to the usual barrage of negative views this overworn term conjures up. It is unfortunate that a more balanced perspective on the dramatic changes occurring in health care, so often lumped together as “managed care,” was not presented. Rather, the study was a beauty contest in which managed care was not as pretty as the authors' perception of fee-for-service medicine nor as attractive as their fantasy of a single-payer system.
A remarkable and seldom-told story of the 1990s is the transition from independent private practices to organized delivery systems. In addition, the outrageous inflation of health care costs of the 1970s and 1980s has been contained through population-based financing. This has put providers of care at risk for their decisions. These changes have already begun to reduce the widespread variability in the quality of health care by causing providers to focus on measurable outcomes of care for defined populations and accept responsibility for improving outcomes within these systems. As Chassin and Galvin report in the Institute of Medicine National Roundtable on Health Care Quality, “Quality of care is the problem, not managed care.”1 Popular or not, this is the current reality of American medicine. Tomorrow's physicians must be prepared with the requisite knowledge, skills, and attitudes to thrive in a new environment. Admittedly, it is more challenging to practice where finite resources are recognized and where decision making includes considerations of whether treatments are cost effective as well as medically effective. But that is the very real challenge we face. The public and medical professionals want physicians, and not administrators of health maintenance organizations (HMOs), or government bureaucrats, to remain the primary decision makers for health care. We agree. Who will prepare them for this demanding role? Managed-care bashing is counterproductive. Enlightened medical education for the future is urgently needed.
1 ReferencesGordon K. Norman, M.D., M.B.A.
PacifiCare of California, Santa Ana, CA 92704-6917Joseph E. Scherger, M.D., M.P.H.
University of California, Irvine, Irvine, CA 92697-39501
Chassin MR ,Galvin RW . The urgent need to improve health care quality: Institute of Medicine National Roundtable on Health Care Quality. JAMA 1998;280:1000-1005
CrossRef | Web of Science | Medline
To the Editor:
The Kaiser Permanente medical centers in California have maintained residency programs in a number of disciplines for more than 40 years. These programs are comparable in quality to programs in strong traditional university hospitals. The Kaiser Permanente programs are unique in that the economic structure of the prepaid, staff-model HMO is integral to the functioning of the hospital. This structure in turn becomes rapidly integrated into the model of care that is practiced by the staff and taught to the residents. Cost effectiveness is part of the management of every case in the hospital, and spending the patient's dollar wisely is viewed as an extremely positive contribution to the practice of medicine. The care of patients transferred from outside hospitals is reviewed not only for the medical aspects of these cases but also for the insights they provide into the economic structure of medicine. To a Kaiser Permanente resident, it becomes readily apparent which emergency rooms are ordering expensive tests for the benefit of the patient and which for economic reasons. We are pleased that after three to five years of residency with Kaiser Permanente, more than 30 percent of our best residents have pursued their professional careers with us. These graduates, with their orientation to the best aspects of managed care, have become outstanding physicians within Kaiser Permanente, and a large number of them have moved into administrative positions within the organization.
In an integrated system in which all the participants have goals that are aligned, students and residents can be taught to make decisions about therapy that are in the best interest of the patient and that carry an acceptable cost to the public, who are, after all, the ultimate payers for medical care. The older generation of academic physicians has been understandably unhappy with some of the changes that managed care has brought to their personal and professional lives. In many ways, this was not what they signed up for. It is unfortunate, however, that a disgruntled and possibly misinformed generation is passing that discontent on to the new generation of physicians.
Pamela S. Wald, M.D.
Southern California Permanente Medical Group, Baldwin Park, CA 91706M. Rudolph Brody, M.D.
Kaiser Permanente Medical Center, Los Angeles, CA 90027To the Editor:
I enjoyed Michels's comments about the study by Simon et al. I would very much like to see medical schools and academic centers teach students and house staff that their primary responsibility is to patients (humanitarian medicine) rather than to the rest of society (utilitarian medicine). Unfortunately, some managed-care companies are developing their own residency programs and are becoming actively involved in research.1
The danger of involving HMOs in the mentoring and teaching of house staff is that they will teach these residents their too-often attenuated approach to the evaluation and care of patients. Young doctors trained by HMOs will think, as most doctors in training do, that the type of medicine they are learning from their mentors is state of the art. Irrespective of what philosophy of medicine they were taught in medical school, these young physicians will emulate their teachers, thus lending academic legitimacy to the economically motivated clinical practices of HMOs. Moreover, with HMOs participating in clinical trials of new drugs and procedures,1 these institutions have the opportunity to introduce biases that will affect practice guidelines.2
Physicians trained by HMOs risk being viewed by patients not as their advocates, but rather as skilled cost–benefit analysts.
2 ReferencesDavid S. David, M.D.
2222 Santa Monica Blvd., Santa Monica, CA 904041
Fletcher RH . Who is responsible for the common good in a competitive market? JAMA 1999;281:1127-1128
CrossRef | Web of Science | Medline2
David DS . Evidence-based medicine. Am J Med 1998;105:361-362
Web of Science | Medline
Author/Editor Response
The authors reply:
To the Editor: We appreciate the impassioned responses to our article. As pointed out by Norman and Scherger, we did not define “managed care”; our reason for not doing so is that we aimed to capture each respondent's own perceptions of managed care. Our pretesting confirmed that managed care means very different things to different people across the country, and we know that managed care does vary, in terms of organizational structures as well as the quality of care.1,2 We agree that the term “managed care” carries prejudice and fails to differentiate types of managed-care programs. The principles that underlie managed care — such as cost containment, prevention, and evidence-based medicine, as well as a documented ability to deliver high-quality care2,3 — would probably not conjure up such vehement negativity.
David thinks it is unfortunate that managed-care companies are involved in research and teaching. We disagree. Wald and Brody describe the outstanding residency training programs at the Kaiser Permanente medical centers. Managed-care organizations, such as Kaiser Permanente, Group Health Cooperative of Puget Sound, and Harvard Pilgrim Health Care, can and do serve as models of excellence in research and education, and as in other settings, these academic activities contribute to excellence in clinical care.4 Although our results can be generalized to a national population, they cannot be applied to populations at particular localities or institutions.
We recognize that there are multiple possible interpretations of our results. We certainly appreciate the “extraordinary seriousness” of the respondents' criticisms of managed care. As we point out in our article, these negative attitudes may signify both inadequate education in and about managed care as well as a “fundamental concern about managed care itself.” The reservations, resistance, and opposition we describe clearly indicate a need for further evolution of the health care system. The finding that approximately 57 percent of respondents favored a single-payer system was indeed interesting and provocative, especially given that the result was consistent among students, residents, faculty members, and deans. Because that finding was based on a single item in our survey and because our survey did not explore what delivery structure would underlie such a single-payer system, we consider the finding to be a call for further exploration.
Brett misunderstands both our argument and our affiliation. The Department of Ambulatory Care and Prevention is a unique research and teaching unit, a joint venture of Harvard Medical School and Harvard Pilgrim Health Care, which is a not-for-profit managed-care organization. Harvard Pilgrim's sponsorship of our research study, with its potentially discouraging findings, attests to this organization's commitment to supporting unbiased research and medical education.
4 ReferencesSteven R. Simon, M.D., M.P.H.
Harvard Pilgrim Health Care, Boston, MA 02215Richard J.D. Pan, M.D., M.P.H.
University of California, Davis, Medical Center, Sacramento, CA 95817Susan D. Block, M.D.
Dana–Farber Cancer Institute, Boston, MA 021151
Iglehart JK . Physicians and the growth of managed care. N Engl J Med 1994;331:1167-1171
Full Text | Web of Science | Medline2
Miller RH ,Luft HS . Does managed care lead to better or worse quality of care? Health Aff (Millwood) 1997;16:7-25
CrossRef | Web of Science | Medline3
Hellinger FJ . The effect of managed care on quality: a review of recent evidence. Arch Intern Med 1998;158:833-841
CrossRef | Web of Science | Medline4
Moore GT ,Inui TS ,Ludden JM ,Schoenbaum SC . The “teaching HMO“: a new academic partner. Acad Med 1994;69:595-600
CrossRef | Web of Science | Medline
Author/Editor Response
These letters illustrate the unusually wide range of views held by the medical profession with regard to the recent changes in the American health care system that have come to be symbolized by the phrase “managed care.” Norman and Scherger applaud “the containment of the outrageous inflation . . . of the 1970s and 1980s” and the reduction of “variability in the quality of health care,” whereas Wald and Brody tell us that residents trained by those who are enthusiastic about the new system identify with their teachers and share their values. On the other hand, Brett suggests that teachers who show such enthusiasm may have a conflict of interest, and David sees “danger” in “involving HMOs in the mentoring and teaching of house staff,” and of “lending academic legitimacy to the economically motivated clinical practices of HMOs.”
Simon and colleagues demonstrated that the majority of academic physicians view “managed care” quite negatively and that this view has had strong influence on students and residents. Norman and Scherger think that the majority are wrong. Wald and Brody go so far as to offer an ad hominem explanation for physicians who are critical of managed care as “a disgruntled and possibly misinformed generation.”
We should work to resolve these conflicts rather than merely transmit them to our students. If the current discontent can be transformed into a renewed dialogue within the profession, we may be able to reconcile the values of academic medicine and the practices of the health care system so that students can learn what will help them to practice and to practice what they have learned to value.
Robert Michels, M.D.
Cornell University Medical College, New York, NY 10021
