(excerpted from an article by George Nobbe in The Medical Herald, July 1996 issue)
[September 1996; Vol. 23 No. 3]
Managed care, a health care system once scorned as far too socialistic to ever be widely embraced in a free market economy, now appears to have won grudging acceptance..., however, growing resistance...has emerged from physicians, hospitals, and...some of the nation’s bigger corporations... [T]his new opposition, health policy specialists told The Medical Herald,...may topple the insurance industry from its pre-eminent position at the controls of the managed care industry.
Recently, for example, Joseph Cardinal Bernardin, Archbishop of Chicago, warned that managed care’s obsessive concern with stemming rising costs could overwhelm the nation’s fundamental health care values. “Has managed care brought improvements over the methods of financing and delivery it is replacing?” the cardinal asked. “Are there things of value that are being lost?” Speaking before the International Association of Catholic Medical Schools, the cardinal warned, “Managed care contains within it the potential for creating as many problems as it solves.”
William Lee Kissick, M.D., and Ph.D., a professor of health care systems at the University of Pennsylvania’s Wharton School of Business, believes that managed care has already gone to excess. “I think part of the reason for that is that we are an adolescent society with adolescent expectations, always seeking perfection and excess.” Like most social change in the United States, nothing about the present health care reform movement is very new. Even the group health cooperatives that today are called health maintenance organizations or HMOs, have their origins in World War II, some of them even earlier.
“...[A]n evolution to legislation...created federal support for the development of HMOs in 1974", said Kissick, the author of “Medicine’s Dilemmas: Infinite Needs Versus Finite Resources.” “The managed care that we are seeing now is an outgrowth of prior authorization, second opinion utilization review, diagnostic-related groups, resource-based relative value scales, and therapeutic protocols,” said Kissick. “It is an effort of the payor to control delivery of service. The ultimate goal, of course, would be universal coverage, which was what Clinton proposed initially. The tactic appears to be attaining it in a series of incremental steps. “I think we will get to it. We have only been working on it for 60 years. My guess is, give us another decade or so, we might get there. It took the Canadians 50 years.”
He noted that for the last century the United States has had four kinds of medical care, which he identified as: entrepreneurial, which is investor-owned; eleemosynary, charity-owned or not-for-profit; ecclesiatical or church program; elected or public institutions. “Right now the proprietary are on the upswing. But I think that consumers, the individual subscriber or a Fortune 500 company is going to get a little annoyed when they realized that 40 percent of the premium is going into profit.”
Allan Rosenfield, M.D., dean of the School of Public Health at Columbia University in New York, where he is professor of obstetrics and gynecology and public health said “in terms of the quality of care, if a major employer finds that its employees are increasingly complaining about the quality of care they are receiving, that message will be transmitted back to the provider. So the quality of care is going to be important in managed care,” he reasoned. “...[T]he doctors are concerned about the amount of time allocated to see the individual patients, about being rushed, about some of the disincentives in some circles to see referrals in specialty care, with more emphasis being on primary care,” said Rosenfield. “I think we will end up with fewer specialists in the future than we have had in the past, but we will have specialists, certainly,” he continued. “The mechanism by which the preferred drug is chosen is going to be difficult and may change from plan to plan. I think that in different parts of the country we are in different stages of managed care evolution. There is no answer for the whole country,” he warned.
In Chicago, meanwhile, Cardinal Bernardin, making his fourth major address on medical matters in the last two years, said that the ultimate goal of any health care reform should be to cover the broadest possible spectrum of American society. He said neither education nor health care research should be neglected. “Without proper diligence, we would find that economic goals supplant health goals and that the trust that is so essential to the doctor-patient relationship becomes undermined by financial incentives,” he continued. “We have the opportunity and the obligation to manage managed care so that it advances the goals of human diginity and the common good,” Bernardin said.