| The delivery of health care services is an intensely personal activity.
Patients necessarily place their physical well-being in the hands of other
persons, either physicians or other providers. Because health care technology
and the science of medicine(1) have progressed
so swiftly over the past hundred years, the focus and direction of the
relationships among the parties involved in the delivery of health care
have changed dramatically. As technology and science developed, the cost
of transferring skills and services from the provider to the patient grew
geometrically. In the days when the physician-patient relationship was
considered more art than science, delivery consisted of a one-to-one transfer
of skills. The physician looked at the patient, listened to a description
of the patient's symptoms, conducted a few very simple tests, prescribed
drugs or conduct that the physician believed might help, and promised to
return later to see if, in fact, she had helped. Today, as medicine moves
more toward science and technology, the physician is likely to use looking
and listening only as a starting point. She then refers the patient for
sophisticated machine testing of many varieties and for more looking and
listening by other providers having narrow specialties. The end result
is a final diagnosis that takes into account the expertise of perhaps dozens
of people.
As these changes have made the practice of medicine more and more complex,
the cost of health care delivery has increased and has become a national
concern. At some point, the cost becomes greater than the benefit. We are
now involved in a search for a new means of determining when, to whom,
and how much of such services we, as a nation, should provide. This search
has been characterized as the need for cost containment. It is being carried
out in many ways and in many areas of the health care industry. One view
of acceptable limitations on the delivery of health care is called "managed
care." But managed care, like other programs in the past, has become so
focused on the problem of cost that it may very well be losing sight of
what should be the overriding purpose of health care-the well-being of
the patient. After all, the patient is the raison d'etre for the entire
system. The patient's well-being is not directly aided by cost containment,
but the patient's well-being is the focus of other important health care
issues, such as quality of care and access to care. The manner in which
cost containment, quality of care, and access to care interact and the
priorities given to them will determine the future structure of our nation's
health care system.
We now seem to be entering into a new phase of health care delivery.
A hundred years ago, the physician-patient relationship was the core of
the health care system. That relationship remained central to any health
care delivery changes taking place until around 1970. Even with the introduction
of third-party payers in the form of insurance plans, the physician-patient
relationship remained unaffected. The physician determined what services
would be delivered to the patient; the patient received the services, having
paid premiums (or having premiums paid for his benefit) to the third-party
payer; the third-party payer either reimbursed the patient or paid the
physician directly. The third-party payer simply had no right to affect
the physician- patient relationship and, in fact, did not affect that relationship.
After 1970, however, a new triangle of relationships came into being.
In this triangle, the third-party payer not only contracts with the patient
to finance the patient's health care needs, it also contracts with physicians
and other providers to provide those health care needs. Two problems arise
from this second contractual relationship. First, through "utilization
review," the third-party payer assumes the right to direct the means and
methods of providing the health care services. Second, through its contracts
with providers, the third-party payer induces compliance with utilization
review by means of financial rewards and penalties, or financial "risk
shifting."
These two new aspects of health care relationships, utilization review
and financial risk shifting, create the possibility that patients
may be injured in totally new ways. Before the new relationships were created,
the only way a patient could be medically injured was through the physician's
conduct. With the advent of the new relationships, patients may be indirectly
medically injured because decisions may be made based on some statistical
norm, not on the patient's individual condition. Further, the patient may
be medically injured by conduct of the physician, not because of the physician's
own decision, but because of a third-party payer's guidelines, with which
the physician is trying to comply. For example, consider the cases of Kim,
Brad, and Barbara.
Kim needs an operation on her knee. Through her employer, Kim has health
insurance with a preferred provider organization (PPO). One doctor, a member
of the PPO, recommends an operation. Another doctor recommends a procedure
that is more expensive but will require less healing time. Kim cannot go
to the second doctor, who is not a member of the PPO, because she cannot
afford to pay for the operation herself. When she has the operation recommended
by the PPO doctor, she takes two months longer to heal than if she had
the more expensive operation.
Brad, a teenager, is suicidal. Through their employer, Brad's parents
have insurance for him. His doctor wants to admit Brad to a psychiatric
hospital. The insurance company, however, requires preapproval of any nonemergency
hospital admission and denies approval. Because Brad's parents cannot afford
the twenty-one day proposed hospital stay, they decide to have him treated
as an outpatient. Five days later, Brad commits suicide.
Barbara, a single mother, is pregnant. She works for minimum wage, but
qualifies for government health insurance. Because the government health
insurance pays doctors significantly less than what they would receive
from other patients, there is no doctor in her immediate community who
will accept her health insurance. The nearest doctor is one hour and two
bus transfers away. Because of the three or four hours she would have to
miss from work, Barbara does not receive adequate prenatal care. Her baby
is born premature and has a low birth weight.
These three hypotheticals illustrate situations in which individuals
may have adequate insurance but may not have adequate health care. As illustrated
by the above stories, private insurers and government health insurance
programs ration care by restricting choice, denying services, and decreasing
availability. They perform utilization review and financial risk shifting
through managed care products such as health maintenance organizations
and preferred provider organizations. Prior to the advent of the new triangle
of relationships, none of the problems illustrated above would have arisen
in exactly the same way they now arise.
Go to: Introduction |
