Inappropriate managed care regimes
Name(s):
Profit-oriented industrialization of medicine
Corporate intrusion into health care
Nature
Managed care as typically practised in health maintenance organizations (HMOs) (as opposed to case management, see below) poses a number of dangers to the health care of individuals with disabilities and/or chronic illnesses. Similar managed-care cost-control techniques in traditional health insurance programmes pose the same risks. Essentially, the problems fall into two categories: (1) those related to economic incentives that lead to under-service, and (2) those related to the nature of this group's health-care needs. Modification of managed-care programmes may remove such dangers, but these modifications are unlikely unless policy-makers change their assumptions about and expectations for managed care.
Background
As used here, "case management" refers to the coordination of care from different providers serving the same patient. This often involves the use of a primary care physician, or a nurse, who serves as the coordinator. "Managed care," on the other hand, refers to a health plan that, among other things, uses economic incentives to hold down costs. One of the goals here is to reduce or eliminate services that are deemed ineffective or "unnecessary." Typically, managed-care programmes pay providers on a capitation (per patient) rather than a "fee-for-service" basis and use primary care physicians or other providers as "gatekeepers" to control access to care.
Due to the priority given to profit, HMOs may restrict the duration of patients' visits to the doctor and may deny the patient the treatment that the doctor has recommended.
Incidence
In one American state, 14 HMOs cover 45% of the population of patients, and so doctors now largely depend upon HMOs to obtain patients.
Claim
1. Health organizations treat the insurance contract and not the patient. Doctors are being forced to react to the needs of managers, not those of patients.
2. HMO profit-oriented practices can be injurious to patient health as well as a waste of the doctor's time. Patients on complicated drug regimens may not adjust well to the replacement of one of their prescriptions by a cheaper alternative. In the case of maladjustment, the patient must make numerous extra visits to the physician to identify the problem and allow supervision of his recovery. In addition, the HMOs pressure doctors into releasing patients from hospital before they are ready.
3. The per capita payment method encourages doctors not to give patients the best quality care. If doctors receive the same payment regardless of patient health care needs, it is in their financial interest to have patients who require little care, and to spend as little time as possible with them.
4. HMOs want to usurp physicians' authority to determine patient care but want none of the responsibility for ensuring patient health.
Counter-claim
1. More American doctors previously practised privately and many held patients' health to ransom with unfairly high fees. Doctors deserve to be at the mercy of cost-cutting management, for they failed to set their prices fairly when it was in their power to do so.
Aggravates
Aggravated by
Strategy(ies)
Type
(F) Fuzzy exceptional problems