In the late 19th century and early 20th century, the efficacy of medicine and the quality of the doctor-patient relationship took a dramatic upswing. Medical milestones – such as anesthesia, antisepsis, antitoxins, antibiotics – at last meant that doctors could really do something to cure disease, to alleviate suffering, and, indeed, to prolong life. And patients responded by placing unprecedented trust in their doctors. And society then responded by affording the medical profession the honor and the authority and the wealth and the power to which it became accustomed in the middle third of this century. But then came the breakdown of the socalled “payer-provider pact.” In its heyday, from World War II until [the 1980s] or so, the payer-provider pact meant that, in
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sense, managed care means that no longer will doctors be able to do whatever they want to do and to charge whatever they want to for doing it. Economic factors began to alter the doctor-patient relationship as never before, as more people – insurance clerks, business CEOs, company controllers, and a variety of bean-counters – in their combined efforts to hold down costs, crowded into the doctor’s office to intrude into a relationship that, until recently, had been just between a single patient and a single physician. Now, while I am a believer in and a beneficiary of the free-enterprise American economy, I have some real reservations about the ability of market forces alone to do what is best for the health of the
am deeply concerned about the millions of
Americans
who live in poverty on the very fringes on this otherwise affluent society, our fellow citizens for whom marketdriven health care will offer less and less.”
most cases, insurance companies willingly paid whatever physicians charged for whatever it was that they did. While it lasted, it meant for most Americans, for the first time in history, economic considerations were usually removed from the patientdoctor relationship. Then, as health-care costs soared out of sight in the 1980s, driven up by a variety of factors – expensive technology, malpractice expenses, the need to practice defensive medicine, physicians’ fees, an aging population, and so on – the payer-provider pact came undone. The people who paid the most healthcare insurance – that is, companies, businesses, and taxpayers – said, “Enough is enough.” And suddenly, economic issues once again began to play a major role in doctor-patient relationships. These economic issues lie behind the managed-care movement. In its broadest
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American people. I am deeply concerned about the millions of Americans who live in poverty on the very fringes on this otherwise affluent society, our fellow citizens for whom market-driven health care will offer less and less. I don’t want my remarks to be interpreted as a diatribe against the negative effect of managed care on the doctorpatient relationship. In some ways, managed care could make that relationship even better, as some recent studies on Medicaid patients who were shifted to managed care have shown – higher patient approval with managed care than in the previous system. And recently, some managed-care groups have taken seriously their obligation to the community, even those who were not their clients. But it seems clear that the demands for economic efficiency will mean that doctors
will be forced to spend less and less time with each patient; and that will have a corrosive effect on the doctor-patient relationship – particularly at a time when medicine is much more complicated than it was, and when patients seem to want to know more and more. The most disturbing impact of managed care on the doctor-patient relationship is the way in which managed care can create a financial incentive for the physician to withhold necessary medical treatment from the patient. This could create a very dangerous conflict of interest between the doctor and his patient and could threaten to eradicate what trust remains between physician and his patient. But we also need a revitalization of physician professionalism and a refined understanding of patients’ rights as well as their responsibilities. I think many of the problems that managed care has presented to medicine might have been avoided to some degree if physicians had not let their sense of professionalism languish. Members of a profession are expected to police themselves, but we must admit that medicine – along with some other professions, particularly law – has too often coddled the bad apples instead of removing them. I imagine that very few Americans today would say that physicians embody an ethic higher than that of society at large, as once was the case. Finally, members of a profession are expected to place the interests of those they serve – patients, clients, students, etc. – above their own interests. And managed care will either bury this hallowed hallmark of the medical profession, or this commitment to professionalism will correct many of the problems of managed care. And along with a refurbished commitment to medical professionalism, we also need a revitalized patient-rights movement which can draw the best from managed care.