Caring for [Retail] Patients -or- [Wholesale] Populations

By Render S. Davis; MHA, CHE

Crawford Long Hospital at Emory University

Atlanta, Georgia, USA

In today’s health care environment, physicians face a myriad of dilemmas in their daily practice. Time constraints, diminished professional autonomy, declining incomes, explosive growth in technology, and deteriorating public trust combined with increasing public demands are only some of the most obvious problems plaguing practitioners. Although some who have been adversely impacted by these changes are quick to lay blame at the foot of “Managed Care Organizations (MCOs),” this anger may be, to some extent, misdirected.

Managed Care

While there are ample faults in managed care as it is currently practiced, its theory and principles are ethically sound. Healthcare should be “managed” – for continuity, quality, value, and optimal outcomes – regardless of the mechanisms by which the caregivers are paid.  Practicing medicine within managed care still entails obligations to care for patients and to respect their autonomy, but now providers have been placed in a disquieting role as resource managers, requiring a new approach to finding better, more cost-effective ways to meet these obligations, while being held accountable to a larger community to which the individual belongs (e.g. a health plan or employee group) for the costs incurred in delivering care. 

For example, an article in the Hastings Center Report, summed up this new approach by noting that managed care is based “…on the foundation of a philosophy of care that, however well or poorly articulated, responds to the needs of individual patients in the context of population-based mechanisms to assess needs and distribute resources…”

Current Examination

In light of the above ethical principles, an examination of the current practice of managed care reveals an uneven and troubled landscape that continues to be impacted by declining sources of revenue for non-profit managed care organizations and falling profits for the proprietary companies.

Across the board, both types of MCOs have been damaged by the precipitous drop in investment income in the wake of the stock market’s decline since 2000 and again more recently in 2007 and 2008.

Consequently, to maintain adequate services or meet shareholder expectations, managed care organizations have further restricted coverage and/or pushed up premiums to either employers or enrollees.

A Public-Good

Although MCO emphasis on health promotion and illness prevention is viewed as a public good, there remain many highly publicized instances where the health of individual patients has been jeopardized by apparently arbitrary policies and decisions made by managed care organizations, ostensibly in the name of cost containment.  Among especially notable issues have been: 

• Delayed referral of patients to specialty physicians, or denials of access to specialized services, primarily based on resource allocation and cost considerations;
• Rigidly enforced practice guidelines and programmatic standards that potentially penalize a physician’s exercise of his or her clinical judgment;
• Crafting of incentives that encourage physicians to withhold clinically pertinent information from patients, and to discourage physicians from serving as advocates for their patients;  
• Declining consumer choice of health plans and providers where consumers with health insurance are unwilling to demand improvements for fear of losing the coverage they have;
• Failure of many MCOs, especially those operated as proprietary entities, to acknowledge an obligation to improve community health and broaden access to services to persons such as those with handicapping conditions, the poor, the disenfranchised, undocumented aliens, and others with legitimate, unmet, health care needs;
• Subordination of quality access and treatments in favor of cost containment, etc.

But, these issues, according to John LaPuma MD, make managed care “morally vulnerable” and fraught with public suspicion regarding its core values. Consequently, physicians practicing medicine today are faced with very real dilemmas in such areas as patient advocacy, access to and scope of care, informed consent, conflict of interest, continuity of care, and patient choice.

“Double-Agency” Dilemma

In a speech given at Georgetown University some years ago, Marcia Angell MD, Executive Editor of The New England Journal of Medicine [NEJM], described the physician’s primary dilemma within the framework of managed care practice as one of “double agency,” where physicians are being asked to be “both advocates for individual patients and allocators of finite healthcare resources to the larger populations of enrollees of health plans.” 

This is a role that seems to impinge on the fundamental tenets of patient advocacy articulated in the Hippocratic Oath.  By the terms of many managed care insurance plans, a physician’s income is directly related to savings generated in the delivery of care, a tactic criticized by former Surgeon General C. Everett Koop, M.D. who wrote, “Something is wrong with a system that spends more and more each year to provide less and less service.”

ROI and Shareholder Value

Many of the proprietary (for-profit) managed care organizations acknowledge their primary business objective is the return of value to shareholders and increased ROI, with obligations to provide expanded access and broader health care coverage to plan enrollees a secondary consideration. Yet, as regular readers of the Executive-Post are aware, some non-profits are not much better!

While he was Speaker of the Oregon State House, former Governor John Kitzhaber (a physician) addressed this concern when he wrote of the “insidious problem permeating our health care system…the perverse set of incentives that leads health care providers to act as isolated economic entities focused on their own well-being, instead of viewing themselves as community resources whose primary role is – or should be – to promote the health of the nation.”

Conclusion

And so, in light of this troubled ethical and moral environment, please comment on some of the specific dilemmas confronting physicians in daily practice; and please include your solutions?

And, when Marcia Angell MD, of the NEJM, called today’s doctors – “allocators” – did she mean that physicians should now become healthcare economists, too?

Related Information Sources:

Practice Management: http://www.springerpub.com/prod.aspx?prod_id=23759

Physician Financial Planning: http://www.jbpub.com/catalog/0763745790

Medical Risk Management: http://www.jbpub.com/catalog/9780763733421

Healthcare Organizations: www.HealthcareFinancials.com

Health Administration Terms: www.HealthDictionarySeries.com

Physician Advisors: www.CertifiedMedicalPlanner.com

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Filed under: "Doctors Only", Career Development, Ethics, Managed Care, Op-Editorials | Leave a comment »