Subject: Managed Care
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?
(1) I would expect that if a patient is not covered for some more expensive tests or whatever, that there might be some tendency not to tell them at the point it matters. Easy to say if it is a private doc who only takes a certain group insurer's patients. Not so easy, or likely, if its an HMO where the doc is an employee of the insurer who is constricting coverage.
(2) I would expect, maybe, as the managed care thing heats up, that competing insurers will have to make some sort of public disclosure as to where they are making such choices. I would expect a push for this, but do not see how it can be that successful as what is not cost- effective in any one situation may be the only option in another. There are thousands of situations where the most expensive response may or may not be cost-effective-how to inform the public of all these choices that each insurer will make, generally or ad hoc? So I am not sure that "medical consumers" can be adequately informed up front (nor at the point of need). For them it will be all retrospective and the choices of insurers made by vague anecdotes, the quality of advertising, etc. And also by cost of insurance and my one thought here is that one should beware bargains and expect to get what one pays for. Will the better off get more than the less better off? Sure: but what else is new?
(3) Your comment about the only thing being scarce is health care dollars alarms me. Police protection, funding for the arts, college tuition support, research funding, etc. ad infinitum are all scarce now. Dollars are just a way to keep score. Where, and how, in effect, will we allocate which of our limited riches? And how much will we place the next generation in hock, undermining its prospects and future, for what we are unwilling to pay for now? If there is justice, the post war spendthrift generation will be told, when they need it, that they have already spent their social security, etc.
(4) If you want to hold down costs, I see no reason to hammer health care professionals as opposed to any one else. Why not the lawyers who are opposing tort reform? Or the bureaucracy and its regulations? And if you take the profit out of manufacturing and pharmaceuticals, people will just invest elsewhere. Or how about an assault on middle class mortgage deductions (hardly a business expense) or cheap state universities? This money (from taxes or less expenditures) could go to health care. The problem is that everyone wants the other person to give something up or pay more. Therefore: no one is willing to give an inch.
(5) And where, by the way, is all this profit you speak of? My wife, a R.N. with 15 years experience, makes about 2/3rds of what a similarly educated and experienced high school teacher makes. Some docs earn outrageous fees but many do not even make 100K a year, the vast majority less than 200K, and when you calculate this in terms of work hours, the years of postgraduate study, etc., etc., then you can hardly describe this as rampant greed. And if we want the "best and the brightest" to come into medicine, we better stop making it increasingly unattractive to them.
I would submit that we have to accept that our resources are limited, that our expectations must correspondingly constrict, that we should pay as we go, that most people will not get the best health care ("decent" is the word I hear abroad), and that the political leadership has to lead by making all this clear and asking everyone to share the burden to some extent. And we are not even close with an electorate that wants it all, but does not want to pay for it. As Allen Ginsberg said: "America how can I write a holy litany in your silly mood?"
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Stephen Wear, PhD
Co-Director, University at Buffalo Center for Clinical Ethics
and Humanities in Health Care
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Jack P. Freer, MD
JFreer@ubmedb.buffalo.edu
as416@freenet.buffalo.edu
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