Would you care to comment on some of the ethical issues of managed care? My concern is the lack of patient's ability to have a say in the type of medical treatment afford them under managed care. For example, to conserve "heathcare resources", some patients may not be able to treated with some of the more expensives diagnostic tests or treatments. The patient may not be fully informed of his/her alternatives because some of the alternatives may end up costing more money. Shouldn't the patient be allowed to take some responsiblilty for their healthcare.
I put the words "healthcare resources" in quotes because the only scarce healthcare resource that I see is healthcare dollars. There certainly is not a shortage of healthcare workers (nurses, doctors, technicians, etc), nor is there a shortage of MRI, CTS, or other equipment, nor is there a shortage of medical supplies. Each of these can be puchased.
It is my contention that all healthcare organizations (pharmaceuticals, manufacturers, suppliers, hospitals, physicians, etc) need to reexamine their responsibility to society. I am not opposed to organizations and businesses making a profit, but is it neccessary to have such a large profit margin at the sake of the patient?
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Response by Maurice Bernstein, MD:
Managed care is a general description of a current trend of medical care in which there often is a different form of payment to physicians and more control of costs by third parties (insurance companies, HMOs and others) and the beginning of attempts to find more efficient and effective ways to make diagnoses and to treat illness. Goals of managed care include providing good medical care while reducing the cost of health insurance to the subscribers and at the same time making a profit for the third party companies. The latter two goals are being accomplished; there may be some debate about the first. There certainly are ethical issues involved in managed care under capitation (payment of all services being the responsibility of a designated provider who is given a fixed yearly payment for each subscriber) as there was previously in the era of the independent physician who operated under a fee for service system. Fee for service lead to the possibility of unnecessary service. Capitation leads to the possibility of too little or inadequate service. Both may be in the better interest of the provider but not in the best interests of the patient. Conservation of health care resources can be part of cost control but some resources may be precious and limited such as blood or transplantable organs.
Though not all expensive tests or treatments are clincally the best for the particular patient's condition nevertheless good patient care should not be limited by unreasonable attention to cost control. There are, however, ethical considerations about which patient should get what at the expense of some other patient or at the expense of the provider or managed care organization.
Current ethical thought is that under both systems of care, the patient should be an active participant in decision making. The patient should be fully informed by the physician about the facts of the illness, the various tests and various treatments that are appropriate. However, generally, the decision of which test or treatment is appropriate is made by the physician using his/her professional education, experience and skills. Often the physician has to take into account the values and desires of the patient.
Treatment decisions require informed patient input and consent. Always, the patient has the right to refuse a test or treatment that the doctor advises. Managed care is still in its infancy and there are many problems, inequalities and inconsistencies which need to be worked out. Careful scrutiny should be made by the public of these issues, followed by strong expressions of public opinion directed to the managed care organizations will be helpful in keeping managed care from becoming ethically mismanaged.
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Maurice Bernstein, M.D.
Assistant Clinical Professor of Medicine
University of Southern California
School of Medicine
DoktorMo@aol.com
ad547@lafn.org
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Jack P. Freer, MD
JFreer@ubmedb.buffalo.edu
as416@freenet.buffalo.edu
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