Originally posted by elias514
1. Managed care is a cost-containment measure. It's very purpose is to MINIMIZE the cost of health care. One way that HMO's and PPO's, both of which are examples of managed care, minimize the cost of health care is to require prior approval for hospitalization, which is VERY expensive. Costly procedures or tests also require prior approval. At their very best, managed care organizations efficiently provide excellent health care at a moderate overall cost; at their worst, they provide poor health care (there are particularly egregious instances of this) without any financial savings. Indeed, the fundamental problem associated with managed care, from a financial standpoint anyways, is that there is a fine line between efficiency and medical malpractice--managed care organizations strive for the former but often wind up with the latter. When the bottom line (i.e., profit) supplants the patient as the primary concern of a health care delivery system, the patient will suffer. BTW: According to several scholars of public health, managed care has been a failure from the vantage point of cost containment. The United States continues to spend more than any other industrialized nation on health care (as a percentage of GDP), and yet the US has some of the worst health outcomes among these nations. Simply put: the health care system in the US remains ridiculously inefficient, the existence of managed care notwithstanding.
2. Managed care restricts the autonomy of physicians. This is a major issue for physicians who are part of HMO's. HMO physicians are not afforded as much latitude in their medical decisionmaking as physicians who are not affiliated with any HMO. Here's a classic scenario: a patient goes to a primary care physician (e.g., a family doc) because of abdominal pain. The family doc assesses the condition of the patient and concludes that the patient needs to undergo an expensive surgery by a specialist. The family doc has to function as a "patient advocate," meaning that he/she must CONVINCE the HMO that the surgery is necessary. Prior to HMO's, no "patient advocacy" was required for a referral to a specialist. Nowadays, primary care physicians function as "gatekeepers," meaning that they control the flow of patients to care of specialists. As gatekeepers, primary care physicians must assume a dual role--i.e., they must constantly juggle both the corporate interests (profit margin) and patient interests. Sadly, the former often trumps the latter, and the patient suffers.
Specialists often do not have as much latitude regarding expensive tests and procedures. If a specialist wants to run an MRI, the HMO may not reimburse him/her for this test; without reimbursement, the specialist will not run the test. This can lead to catastrophic results for patients, because certain expensive tests are vital extensions of a physician's eyes and ears--they enable physicians to make tough diagnoses. If a condition goes undiagnosed, an easily treatable condition can escalate into a very costly, life-threatening disorder. There are numerous instances of this in medical literature, and I myself know a person who suffered (lost an organ) from the excessive cost containment measures of HMO's.
3. Managed care interferes with the doctor-patient relationship. In addition to the patient advocacy discussed above, some HMO's set caps on the amount of time that a doctor can spend with a patient during consultations (e.g., 15 minutes). Others provide "capitation payments" to physicians in the HMO, meaning that they are reimbursed at a flat rate for patients, regardless of medical conditions treated. In effect, there is no financial incentive for physicians subject to capitation payments to spend extra time with certain patients, since they get $100/patient or whatever. Capitation plans force primary care physicians to increase the volume of patients that they see every day, thereby decreasing the amount of time that physicians spend with each patient. When profit becomes paramount, the patient suffers.
4. Managed care restricts the choice of providers for patients, a restriction that borders on the absurd in some cases. In principle, patients in a particular HMO or PPO can see any physician they want; in practice, this is not true, because HMO's typically require considerably higher copayments for services rendered by doctors, who are not part of the HMO or PPO. Case in point: I have a $20 copayment for outpatient care by any "preferred provider"; however, I can see any physician, provided that I am willing and able to pay 50% of the cost out-of-pocket. What the hell kind of "choice" is that? If the cost of a doctor's visit is 400 bucks, then I can either pay $20 at a preferred provider or $200 at some non-preferred provider. Geee, I think I'll "choose" the former. In some documented cases, preferred providers or physicians in the HMO are not even in the same city as the patient!
I have presented a negative portrait of managed care, because I think that managed care represents a failed attempt at fixing our nation's broken health care system. Nonetheless, there are benefits to the managed care approach. As I said before, managed care, at its best, provides excellent health care in an efficient and financially sound manner. By minimizing hospital stays, restricting access to the expensive care of specialists, and eliminating unnecessary tests and procedures, the cost of health care in America can be contained in a safe manner, provided that profit does not override the well-being of the patient. Moreover, managed care organizations offer doctors more relaxed schedules (e.g., less call), which is good for recent med school grads who favor the "shift" mentality. In spite of these perceived benefits, managed care in reality presents an inexcusable intrusion into the doctor-patient relationship, damper on the authority of physicians, and threat to the health of patients.
Hope this helps.
BTW: If you want a good introduction to health care in America, you ought to read the following books: The Social Transformation of American Medicine, As Sick As It Gets, Health Care Meltdown, Bleeding the Patient: The Consequences of Corporate Health Care, and the textbook for a survey medical sociology course.
