December 1997 XIX/4
HANDLING THE 800 POUND GORILLA
As everyone knows, managed care has become the 800 pound gorilla dominating the American health care community. How does one handle an 800 pound gorilla? Very carefully! One interesting aspect of this new phenomenon is that there are several descriptions of managed care. The most accurate description seems to come from John Iglehart: "Managed care seeks to reduce health care costs and improve quality of care by controlling choices traditionally made within the patient-physician relationship." Like any 800 pound gorilla, managed care has the reputation of being primarily destructive. Yet, even a consistent critic of managed care admits: "The inherent virtues of managed care have manifested themselves in many salutary improvements to the system that might otherwise never have been made. Those include attempts to eliminate waste and redundancy, a greater focus on health promotion and disease presentation, more attention to the management of chronic diseases, a focus on the accountability of physicians and health plans on the quality of care, lower hospitalization rates without an obvious decline in the quality of care, heavy investment in patient information systems and control of employer health care costs." (1)
In spite of these positive potentials, managed care plans have dark reputations in the minds of many patients and most physicians. A recent survey by a public relations firm of 589 recent citations in newspapers, magazines, and transcripts from television news programs found five unfavorable stories about managed care for every favorable one. In a national pole to rate industries in relation to service for consumers, managed care companies were ranked second from the bottom, only above tobacco companies. Managed care is associated in the media with denial of care, gagging of physicians, callous treatment of women after childbirth and mastectomies, disproportionate attention to profits, refusal for emergency room care, and refusal to accept responsibility for medical teaching and research, to mention just a few complaints.
In an effort to dispel negative attitudes and also to limit the potential harm of managed care, two plans have been developed. The first, called Putting Patients First (PPF), was developed by the American Association of Health Plans (AAHP) and features a quality assessment program intended to detect any pattern of underservice, a clinical guideline program aimed at providing information and support for clinical decisions, a utilization-management program designed to evaluate the appropriateness of health care services, and a drug-formulating program aimed at informing physicians about pharmaco-economic information needed for cost effective medical practice. (2) The patients are to be informed of the various processes such as utilization rules, and drug formulary rules, only if they request such information. Compliance with the plan by AAHP members is voluntary. One commentator believes the plan is worthless and is only "a thinly veiled attempt to ward off state and federal legislative actions to curb the abuse of managed care." A more friendly analysis of PPF, is offered by David Jones, a board member of AAHP, who maintains in the cited article that the plan "has teeth" and that it balances competing interests such as cost cutting, unlimited choice and the practitioner's desire to be left alone. (2)
Probably there will not be time to test the value and reliability of the PPF plan. There are two other efforts under development to monitor and correct managed care which might pre-empt PPF. The first, a "Consumer's Bill of Rights," is designed by a 34 member Presidential Advisory Committee. The committee suggested many of the same controls put forth in the PPF proposal but adds a stronger right of appeal. Decisions denying coverage could be appealed in court or to independent arbitrators. Many have complained that enforcing all the regulations of the Clinton plan would increase the cost of health care to the extent that managed care would lose its meaning. (3) Republicans, the popular wisdom maintains, would be reluctant to listen to Clinton's appeals for enactment of the health commission's proposal. They believe that regulation would stifle the market forces which have reduced the cost of health care in the last three years. The Clinton Patients' Bill of Rights might face the same fate as the 1992-93 effort to reform health care, but Congress itself seems intent upon enacting some limits upon managed care companies. Once again, however, Congress faces a delicate balance. If it responds too aggressively to the requests of constituents, it may impede the initiative and aggressive activities that led to the development of HMOs and other beneficial parts of the managed care movement.
While the various efforts to regulate managed care in the U.S. are significant, the question remains: Do they miss the mark? Will they tame the 800 pound gorilla? Three observations question the efficacy of the new regulations. First of all, the efforts of PPF, the Clinton committee, and the various proposed bills in Congress, seem to have in mind the restoration of many pre-managed care procedures. None of the new plans and proposed regulations mention that the paradigm for health care has changed. In the past, health care was primarily concerned with doing everything possible for individual patients. Managed care on the other hand directs the attention of physicians and hospitals toward a group of patients, not only toward the patients who actively use the health care system. In the new paradigm, some of the new practices are reasonable, but they would have been rejected in the past. For example, a consistent practice of managed care allows patients access to specialists only after referral by a primary care physician. Seeking to mandate free access to specialists through law is anachronistic, yet this is the goal of several pieces of Congressional legislation. Secondly; many of the standards put forth to measure the effectiveness of managed care programs are directed toward measuring customer satisfaction, not quality of care. While customer satisfaction must be factored into an analysis of quality care, there are several other elements such as outcome studies and information in regard to competency of individual physicians and hospitals. It is much easier for a patient to express an opinion in regard to promptness in answering the phone (high on :he list for patient satisfaction) than it is to measure the various outcomes for treating myocardial infarction. Yet the latter is a much more important factor in judging quality of care. Quality of care must be emphasized if progress is to be made in health care. Both pre and post managed care medicine are far from perfect. "One-fourth of hospital deaths may be preventable, and one-third of some hospital procedures may expose patients to risk without improving their health. One-third of drugs may not be indicated and one-third of tests showing abnormal results may not be followed up by physicians." (4)
Thirdly; in the midst of forthcoming rules and regulations limiting the behavior of physicians and testing their commitments as well as their patience, perhaps physicians can cut the Gordian Knot of increased regulations by putting into practice the words of an eminent pioneer in the field of measuring quality of care: "I place the interactions of patients and practitioners at the center of the health care universe because I believe it is there that the processes and decisions most critical to quality take place. Here is the atomic furnace where quality is generated." (5) In other words, the profession of medicine then achieves quality of care only if practitioners have empathy for their patients.
At the time of the Punic Wars, all sessions of the Roman Senate were concluded with the declaration: "Carthage must be destroyed" (Delenda est Carthago). As a result of constant repetition, this slogan became a goal of the Roman Republic and was eventually accomplished. With this in mind, every time I reflect upon managed care, its advantages and shortcomings, I am convinced that the only way to solve health care problems in our society is to insist continually that we must have universal health care coverage. Until this is accomplished we are fighting brush fires and ignoring the major conflagration.
Kevin O'Rourke, OP
1. J. Kassirer. "Is Managed Care Here to Stay?" NEJM 336 (April 3, 1997):1014.
2. D. Jones. "Putting Patients First: A Philosophy in Practice," Health Affairs 16 (Nov/Dec 1997):115-132.
3. P. Lee. "The True Test of Whether Health Plans Put Patients First," Health Affairs 16 (Nov/DEC 1997):129-132.
4. R. Brook et al., "Health System Reform and Quality," JAMA 278 (August 14, 1996):476.
5. A. Donabedian. "Quality in Health Care: Whose Responsibility Is It?" American College of Medical Quality (1993):32.
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