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Thursday, May 18, 2006

'Other people's money" and the moral costs of managed care

Dr. Patricia Illingworth is an associate professor of philosophy at Northeastern University and holds a PhD and JD degree. Her writings express well the observations that are commonly made by physicians about the world in which they live and work which is dominated by managed care.

Medical care came to be "managed " by the managed care sector because of the concept of "other people's money". To a large degree individuals pay for only a portion of their health care the remainder paid by either employers or the government. There was little issue made by these other people until the costs of health care rose to some threshold above which employers and other third party payers including CMS thought costs were getting out of hand. Then entered cost containment via the various cost savings actions of managed care.

Dr. Illingworth believes that the modification of the traditional fiduciary duties of physicians to patients by the duties of the for-profit corporation vis-a -vis shareholders is the root cause of many ethical problems generated by managed care. Basically the HMO strives to make money or save it and they introduce mechanisms to control physician behavior to that end even if that control involves abrogation of the fundamental duty of the doctor to place the patient first. The efforts of the HMO in that regard weaken the physician-patient relationship and damage the trust element in the relationship.

In her recent book, Trusting Medicine: The Moral Costs of Managed Care she outlines her argument and it is reviewed in the May 10,2006 issue of JAMA. It is gratifying to read an academician express many of the same views you would hear in the doctor's lounge at your local hospital- that is if there still was such a place.

In a review of an article she wrote for Northeasten University Magazine she is quoted:

"Part of the problem is that some commonly accepted principles of business ethics are fundamentally incompatible with traditional medical ethics...

Dr. Illingworth says bluffing (holding back certain information), puffing (exaggerating) and spinning (putting the best face forward on undesirable outcomes) are part of normal day to day business practices but have no place in the physician-patient relationship where honest relationships are essential to good practice. However, physicians dependent upon managed care companies may be influenced and controlled to the extent that their behavior favors the company's bottom line more than the patient's interests in spite of the doctor's effort to swim against the tide.

As the reviewer in JAMA noted, President Bush listed as one of the goals for health care was to "strengthen the doctor-patient relationship". Has the doctor patient relationship eroded so badly that it deserves to be a topic in a State of the Union address ? Maybe so.The erosion of patient trust and the deterioration of the physician-patient relationship are, in my opinion, directly related to managed care. I do not see how the trend can be reversed as long as managed care companies continue to exert hegemony over physicians.

As is so many matters,I have no solution but I do not believe that as long as managed care entities exert their domination over practicing physicians that such things as electronic medical records, having docs audit themselves to see to what degree they adhere to selected guidelines and calling it all a "medical home" will restore the deteriorating doctor-patient relationship.

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