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This page created October 2000 by Michael Wynne
This was part of my original criticism of Samuel's denial of
managed care's problems. It addresses the question of who controls
utilisation of health care services.
Central to the crisis in the USA is control of the utilisation of health services. Until the 1970's it was the doctors, in the 1980's the corporate providers and in the 1990's the managed care corporations. Whoever controls utilisation controls costs and profit. Legally doctors control utilisation and their pens determine cost and profit. Their own fees are only a small part of this. To succeed corporations must gain control of doctors pens. Providers do it by indirect bribes. Managed care does it by contracts which link doctors personal incomes to their pens in ways which benefit the company. This has been used to deny the care for which patients have directly or indirectly paid. Doctors are unhappy and US citizens are angry.
The New York Times reports that doctors and
patients are now walking away from managed care in their thousands. A
few years ago doctors who refused to join HMO's starved. They no
longer have a shortage of patients and their colleagues are resigning
from HMO's and joining them. The consequence as the NY Times
indicates is to compromise equity in that country even further.
Integration will not be facilitated.
Samuel fails to explain how utilisation is
actually to be controlled at the point of care in his model and who
will do that. Who is to decide about the actual care provided? It is
unlikely that it will be the patient whose competitive pressure has
been kept at a comfortable distance from the provider of care. The
patient is likely to overuse and push up costs. It is the government
who is paying.
Samuel is clearly critical of professionalism. To suggest that doctors will be given a free reign in his system is unrealistic. Samuel like the managed care companies claims that doctors have the expertise and will decide. This is not what has happened. In the USA doctors have to go through a complicated process to get permission to treat their patients. Their requests are often refused.
Are doctors expected to form large groups and compete for services by trading the welfare of their patients in order to win contracts? Doctors in the USA felt that by becoming HMO's they could bargain in this way and so protect their patients patients more effectively. It simply did not work. The concept is so foreign to the medical ethic and the duty of care so strong that most groups did not perform well in restricting care. Those that remained viable did so by compromising their mission. Those who succeeded were consequently the least suitable doctors. The majority succumbed to competitive pressures and were taken over by market listed HMO's.
Samuel's claim that the doctor will retain
control of care is not supported by experience. It is not in the
interests of the corporations which are paying for care for them to
allow doctors free reign. Regulations and oversight will not stop
corporate interests from seeking to "buy the use of MD degrees". This
is the not so secret path to success in the marketplace.
The profits of the tendering corporate providers (it seems clear that this is what Samuel envisages) will depend as they always do in the marketplace on the ability of providers to control the decisions made by doctors. Doctors signatures to treatment determine the viability of the corporation and the profits of its shareholders. In the marketplace this is accomplished by a system of incentives and disincentives. Essentially this is a system of kickbacks to staff and to doctors which have been structured in such a way that they skirt around the laws which prohibit kickbacks. This is the practice which has been used to destroy professionalism.
The compromises on care and the misuse of
patients for profit in Tenet/NME and Columbia/HCA - the denial of
care and rationing for profit in managed care corporations were only
possible because the compliance of doctors was bought by corporate
groups of one sort or another. As Ron Williams indicated care for the
patient became care for the corporation.
Samuel should indicate whether incentives are to be used for managers, and professionals and if so what form they would take. Will the people who decide on care relate directly to purchasers or be part of a provider group. Who will control costs, who will decide when rationing is necessary, and who will ration when rationing is required. Who will decide how much money is required for health care and who will balance this against the resources available and make the compromises needed? What sort of incentives will these people be offered and on what will the incentives be based on. Overt and hidden incentives have been the single most important factor in inducing managers and professionals to place the interest of the corporation above that of their patients.
In a corporate marketplace care and profit compete for the same dollar. Rationing care to secure profits for shareholders is socially unacceptable. Shareholders will not invest money unless their directors generate profits. When government or competitive pressures squeeze profit then securing profit by rationing care becomes a matter of corporate survival. This is what the public should understand.