The New Health Care

Main Points

Traditional Medicine: With managed health care, we have gone from the traditional idea that most is best to the concept that least is best. The paradigm for managed care is a mirror image to the way medicine has been practiced in the 20th century in  the United States.

In fact, for at least 50 years, sick people have been coming to the United States from all over the world for our medical care. The American model of care and American expertise in health has been sought by privileged individuals and heads of state from nations large and small. They have come here because our care has been the best and most technologically advanced to be found anywhere.

Power Shift: In the 1990s, power has shifted massively  from patients and doctors to business organizations in the new system of health care. This has had some benefit in controlling costs and removing fat from the system, but it has also removed some of the muscle and in many areas is cutting to the bone.

Streamlined Medicine: The managed health care consumer is purchasing streamlined medicine. It is predicated on increased productivity per health care worker, substitution of less expensive and less skilled health care providers for more expensive nurses and doctors, and generally reduced use of resources. When pressed to the limit, this becomes analogous to what is called dispensary or battlefield medicine. Decisions about what to do and what not to do are increasingly made by MBA's instead of MD's.

Limiting Care: Decisions about how deeply to limit care are made in board rooms, far from the consultation room where the physician and patient have traditionally decided what is indicated in a particular circumstance. The physician is increasingly bound by decisions made by individuals and organizations without direct experience in patient diagnosis or care. Part of limiting cost is inevitably to be found in limiting care.

Reduced Service: The health care consumer is happy to see the reduced premium and decreased out of pocket costs for services provided by the plan. What the patient does not see so clearly is the reduced service provided. Legislatures have gotten involved in such egregious limitations of care as drive through deliveries and the practice of sending mastectomy patients home the same day. But neither the patient nor the politician is in a position to see the thousands of other less obvious corners being cut in the name of cost control.

The same time and attention cannot be provided by the physician, because the system is so dominated by a drive towards greater productivity. Greater productivity means less time and energy per unit of production.

Why people like managed care: Much of the time most people are healthy. They have been accepting of the new health care organization because they have had relatively little interaction with it, except for simple routine care. All they see, so far, is the reduced out of pocket cost.

Why people do not like managed care: Once they need care, if the care they need is simple and routine, people are likely to remain happy. Managed care can provide this with great efficiency. However, when a problem becomes more subtle or complex, there is tremendous pressure from managed health care plans on their physicians to limit testing, referrals and treatment.

Why might you need your own physician advocate and a Health Advisory?