Correspondence
Patients' Rights Bills and Other Futile Gestures
N Engl J Med 2000; 343:1267-1268October 26, 2000
- Article
To the Editor:
In her editorial on patients' rights bills, Angell (June 1 issue)1 overlooks several important positive features of managed-care systems. Most major managed-care organizations have devoted substantial resources to wellness-related activities, health-promotion and prevention programs, protocols for disease management, and other important quality-improvement strategies. Hundreds of thousands of patients have benefited from managed care's leadership in introducing innovations in immunization practices, more effective mammography, Pap smear, and colorectal-cancer screening programs,2 and the promulgation of appropriate clinical standards for improved management of both acute and chronic disorders, particularly diabetes, asthma, cardiovascular disease, and depression. The preponderance of evidence consistently indicates that with regard to the quality of care, use of services, and access to care, managed care is at least equal and in many cases superior to traditional fee-for-service medicine.3-5
Despite opinions to the contrary, employers have helped drive the principle of accountability not only at the health-plan level but also among the physician and hospital communities. Meaningful issues involving access to care, its appropriateness and quality, service and outcome indicators, accreditation status, costs, and value are now part of the accountability equation for all stakeholders. It is highly unlikely that individual consumers could or would have achieved the same results.
The much-cherished system of fee-for-service care is built on a foundation of highly fragmented, episodic acute care, which has led to a costly and unwieldy health care system with substantial problems in quality,6 widespread variations in clinical practice, and considerable waste and abuse. Managed care is fundamentally an attempt to integrate the delivery of care with the financing of care. Although the execution of operational and supporting programs has at times been less than optimal, it should not be forgotten that this system supports the critical principles of affordable, coordinated, and continuous care focused on prevention, early detection, evidence-based treatment, and superior outcomes. To be certain, there are elements of inconvenience, irritation, incompetence, and frustration, but one should not forget the self-interest, hypocrisy, and wishful thinking that also permeate the current environment.
6 ReferencesDouglas R. Woll, M.D.
Blue Care Network of Michigan, Southfield, MI 48086-50431
Angell M . Patients' rights bills and other futile gestures. N Engl J Med 2000;342:1663-1664
Full Text | Web of Science | Medline2
Riley GF ,Potosky AL ,Lubitz JD ,Brown ML . Stage of cancer at diagnosis for Medicare HMO and fee-for-service enrollees. Am J Public Health 1994;84:1598-1604
CrossRef | Web of Science | Medline3
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 | Medline4
Reschovsky JD . Do HMOs make a difference? Access to health care. Inquiry 1999;36:390-399
Web of Science | Medline5
Tu HT ,Kemper P ,Wong HJ . Do HMOs make a difference? Use of health services. Inquiry 1999;36:400-410
Web of Science | Medline6
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:
Although it is hard for me to disagree with the overall goals and policy positions stated by Angell, especially in the light of declining access to care for uninsured Americans, the effort to limit arbitrary and capricious medical decision making by managed-care organizations through legislation deserves our support. We will not reach the goal of providing high-quality care for every American at a reasonable cost without a struggle. Consumers need a victory to increase their sense of empowerment just as much as we need to keep health care costs at a reasonable level. Moreover, the experience of states with patients' rights laws (e.g., Texas) suggests that the cost of health care insurance has not increased significantly as a result of the implementation of legal protections.
Arnold Birenbaum, Ph.D.
Albert Einstein College of Medicine, Bronx, NY 10461To the Editor:
Months ago, under increased pressure from patients, physicians, and legislators, the nation's second largest insurer, UnitedHealth Group, dropped rules requiring doctors to obtain approval for diagnostic tests, procedures, and hospitalizations. UnitedHealth claims that it dropped these preauthorization rules because it spent more money processing physicians' requests and appeals than it saved denying “unneeded” treatments. Karen Ignagni, president of the American Association of Health Plans, has encouraged the 1000 health-plan executives who are members of the association to consider the example set by UnitedHealth.
Patients' rights bills that require that physicians, not insurers, make decisions about medical necessity may in fact save health plans money by eliminating costly administrative roadblocks set up to discourage physicians and patients from seeking care. By returning the responsibility of making decisions about medical necessity to trained physicians, insurers are also more likely to avoid the costly appeals and lawsuits that result when they deny care recommended by the attending physician.
In view of the money the health insurance industry spends on administrative costs, executive salaries, and lobbying, it is clear that these companies are fully capable of absorbing the modest costs associated with patients' rights legislation. Passing legislation that provides meaningful protection of patients will result in needed competition among health insurers to offer high-quality health care at a fair price. Until this happens, the declining quality of care will continue to erode patients' faith in physicians and in our nation's health care system.
Andrew Fenton
George Washington University School of Medicine, Washington, DC 20037To the Editor:
Two of Angell's statements — “Health care insurance should not be optional, as it is in our employment-based system. Just as everyone over the age of 65 is covered by Medicare, so should everyone under that age be covered,” and “Medicare is far more efficient than the market-based part of our health care system” — are not accurate. All you have to do is look at the other countries that have used universal health care coverage, such as England, the Czech Republic and Slovakia, Sweden, and Canada. They have all converted back to private care to some degree because of the inefficiency of government-run systems. We know that this is true from so many other things that the government runs.
Wallace Rubin, M.D.
3434 Houma Blvd., Metairie, LA 70006-4226To the Editor:
Some attention needs to be paid to the real concerns of physicians who worry that we would be bankrupted and have to stop practicing if all services in our offices were reimbursed at Medicare rates. Medicare would also have to be reformed to cover wellness visits, annual Pap smears, and some other things currently not covered.
Martha J. Brewer, M.D.
4228 Houma Blvd., Suite 400, Metairie, LA 70006Author/Editor Response
Dr. Angell replies:
To the Editor: Woll provides a familiar litany of assertions about managed care, with some highly selective culling from the literature, but it seems to have little to do with today's realities. If managed care is as successful as Woll implies, why are Americans pressing so hard for patients' rights bills? The fact is that the economic incentives of managed-care companies require them to limit services to the sick, and that is what they do.
Birenbaum believes patients' rights bills are better than nothing. My concern is that they will lead to nothing — that is, they will cause the ranks of the uninsured to swell. The essential message of my editorial was that we cannot regulate the medical coverage provided by employers if they need not provide it at all. When regulation causes premiums to rise, as it surely will if it is effective in maintaining services, employers will simply opt out.
Fenton is correct that UnitedHealth Group no longer requires preapproval for certain tests, procedures, and hospitalizations, in part because it costs more money than it saves. The decision to drop this requirement was also good public relations. Yet, my understanding is that the company continues to review doctors' decisions after the fact and retains incentives to limit services. It is simply doing so more efficiently now.
Contrary to Rubin's statement, Medicare is indeed more efficient than the market-based part of our health care system. Its overhead costs are an order of magnitude smaller than those of investor-owned insurers. Some advanced countries are experimenting with permitting private boutique systems for persons who can afford them, but not because of greater efficiency. And no country that I know of is dismantling its national health care system.
Medicare is not perfect. For one thing, it was created in the mid-1960s and reflects the medicine of those times. In those days, the focus was on acute rather than chronic illness, high-technology care of any sort was preferentially rewarded, and there were not many effective drugs. Thus, Medicare needs some updating. In particular, I believe it should cover outpatient drugs and long-term care, and its fee schedules should be less weighted toward technology. The specifics of any changes are debatable, of course, but the basic idea of Medicare is sound. It provides universal coverage for the elderly in a single-payer system with low administrative costs and a free choice of doctors. Would that we all had the same.
Marcia Angell, M.D.
