PerspectivesAre you interested in submitting a Perspective Article? Be sure to read The Science Advisory Board's Editorial Guides for Perspective Articles. Click here. A Historical Perspective on Managed Care by David W. Crippen, M.D., F.C.C.M. A Member Since July 2003 Your righteous indignation must be tempered somewhat by the fact that physicians as a political group had a heavy hand in creating the environment that led to "managed care". Back when medical care was affordable, people paid for it in real time just like groceries. It could be a big hit but it rarely broke anyone. If you really didn't need a service, you didn't ask for it because it forced you to alter your finances around it. Health insurance was affordable for the common man and adequately indemnified him/her from disasters. Enter universal health care for the great unwashed in the form of Medicare and Medicaid (for out-of-towners- these are government sponsored indemnification for the elderly and the poor, respectively). Once that happened, personal liability for purchasing health care services vanished and demand escalated like a V-2 rocket, matched exactly by supply from a burgeoning medical-industrial complex. Instead of "professionals" we became "small businessmen", marketing our services to the community instead of hanging out a shingle and waiting for them to seek us out. The more demand we created, the more we prospered. Physicians and patients danced with the devil in the pale moonlight while the debt silently deepened. Then the bottom of the barrel came into view. Congressional wonks moved to put providers on the front line for blame when inevitable cuts in service came. Patients were encouraged that nothing was wrong...keep on using services (and keep voting for us) but hospitals and providers were cut back in reimbursement by creating "inconvenience blocks"- escalating paperwork, which if not followed to the letter, resulted in non-payment. Computers were set to deny for the smallest infraction of increasingly complex rules. Physicians howled. Hospitals went belly up. The self fulfilling prophesy At this point in time, it could be argued that the handwriting was on the wall for physician related churning of the pot's diminishing contents. Did physicians move to cut back questionable and even unnecessary services (taking personal financial hits in the process)? Of course not. They reacted like constructors of race cars after a change in the rules designed to slow them down for safety. They went to the design boards and figured out how to beat the rules. Every year the Indianapolis Motor Speedway promoters make rules to slow the cars down; every year they go faster. Reimbursers figured out that the only way to stop physician's from churning the pot for their own gain was to create an environment that generated decreasing return for increasing market penetrance, finally to form a negative return system where increases in hype and glitz generated no yield. Managed Care is simply the logical extension of that environment. We (Collectively) brought this on ourselves by refusing to act in such a manner as to slow the onset of default in an overheated system. Our motivations were not all that altruistic; we moved to save our own pocketbooks as much as protect our patients, and now the pipers sour song wafts in through the open window. So here we are. Like Pogo, we have met the enemy and he is us. What can we do about it? You seem to be looking for a Divine Eminence to lead the fold out of this mess. Well, historically there is a sociological premise called the "Great Man Theory". It goes something like this: in every generation there arises great social problems. When any one of these social problems breaks through a threshold, there always arises a "Great Man (or Great Woman) to lead the fold out of danger. Moses, FD Roosevelt, Churchill, Ho Chi Minh, Joan of Arc, Dr. Hunter S. Thompson...I don't know if the medical situation has broken through the threshold yet, or if it ever will, but for such a "Great Person" to arise in the 90s, radically different problems must be surmounted. If you read The True Believer, by Eric Hoffer (1951) you will learn that unseating social systems where there is an entrenched establishment having a strong political and financial incentive for status quo is a violent and apocalyptic process. The only way it can be done is by those who have nothing to lose from the creation of anarchy. The bastions of powermongering in this country have not been sitting idle over the past several decades. They have been learning how to diffuse threats to the dominion's technocracy. One of the main things they learned is: If EVERYONE is part of the system, potential dissenters have more to lose than gain by disturbing the status quo. It wasn't always that way. A bunch of scruffy kids got together and brought down two presidents, radically changing the course of a political establishment. Part of the reason they were able to do so is because they had no investiture in the fruits of powermongering. Conspiring to destroy institutions proceeded because they had nothing to lose and more to gain by creating new institutions. But now everyone, especially everyone in medicine, is a government employee in some fashion. Disturbing the status quo DIRECTLY affects any potential dissenter and makes it much easier to identify and sterilize him/her. Much like the Internal Revenue Service and the (former) Selective Service, managed Care has evolved into a system designed to be bulletproof from external threats it's designers knew would be in constant attack. The only way to undermine what we perceive as "managed care" is to create an environment where the existing system beats itself to death. As a practical matter, that means the only way to beat it is by mass noncompliance. As Malcolm Fisher once remarked: "If four people march into a recruiter's office and sing a bar of Alice's Restaurant and walk out...it's a movement...if fifty people walk in...by God, it's a revolution..." Could we really do it? Lets argue for a minute that this would be feasible; that a mass movement of physicians could snarl up the system and bring it to its knees. First of all, It would require a "Great Man/Woman" to stir the general populace to a Teamster-like frenzy. They are too fragmented to come together by themselves. If MOST physicians could be coerced into, metaphorically speaking, marching into a Medicare/Medicaid office, singing a bar of Alice's Restaurant and walking out, it would bring managed care to a screeching halt in minutes. Several other unpleasant things would occur simultaneously: 1. Government edicts are non-negotiable. Willful noncompliance is illegal. Ringleaders (The Great Man/Woman) would be quickly identified and jailed. 2. The government would immediately move to bring legal sanctions against all participants, bringing at least 50% of their livelihood to a grinding halt as well, plus legal sanctions. Mortgage payments, Jeep Grand Cherokee payments, private school fees, Master Care/Visa card payments, all would come mercilessly due and languish, creating a serious ripple in the general economy. 3. The government would immediately tell patients that the reason their services have been interrupted is because of those greedy physicians who are putting them at risk by acting in a selfish and antisocial manner. What happened to their Oath? Where is their dedication? They have become Teamsters........."we only work if we have our foot on the neck of management". The movement would buckle quickly when the pain began, and then the retribution would begin. To the winner go the spoils. OK, lets argue further that physicians could be whipped up into such a frenzy that Jimmy Hoffa's millions of molecules buried somewhere in a bridge abutment in New Jersey all quivered in syncopation. We pulled it off. We endured the pain and simply outlasted them and the public outcry became unbearable. Little old ladies with blue hair emoliated themselves daily in front of the White House. The Prez wore a flak jacket to breakfast. We beat them and the wonks had to negotiate to save their skins. We would then get to negotiate a NEW DEAL. Unfortunately, doesn't get us out of the woods. One of the fundamental premises of Hoffer's work is that the same people who bring down the system never enjoy any of the fruits of reconstruction. (Castro and Lenin rare exceptions) They are sacrificial lambs and are forgotten when the new wave of negotiators arrive. Read The Seven Pillars of Wisdom to find out what happened to T.E. Lawrence after the truce in the Desert. So the big question then becomes: which one of us is willing to give a shot at becoming the sacrificial lamb for the New Order. Not me. I am too old and soft. There was a time when I would have cheerfully gone to the wall and wailed with the best of them. I now have kids that need fed, clothed, educated. I have a Ferrari that needs a low-restriction stainless steel exhaust system. I have a wife who would never let me live it down. If I were to foment such a rebellion, I would create a painful intolerable environment for me and my family, something I am not willing to do. I am at the mercy of a system that knows it has me by the short hairs. I can crow loudly and posture mightily, but in the end I cannot change anything meaningfully because I am a part of it. So who among us is willing to walk into a Medicare/Medicaid office, sing a bar of Alice's Restaurant and walk out? "Not me....not me.....Julia.....take Julia." ### David W. Crippen, MD, FCCM is Clinical Associate Professor of Critical Care Medicine at the University of Pittsburgh Medical Center. He also holds a secondary appointment as Clinical Associate Professor in the Department of Emergency Medicine. He trained in general surgery, Emergency Medicine and Critical Care Medicine. Dr. Crippen is a member of the Society for Critical Care Medicine, the European Society for Intensive Care Medicine, and the American College of Emergency Physicians. He is a Fellow of the American College of Critical Care Medicine, a Diplomate of the American Board of Emergency Medicine, and the European Diploma in Intensive Care Medicine. Over ten years ago Dr. David Crippen founded an international critical care medicine discussion group on the Internet (http://www.pitt.edu/~crippen/). Today, with over 1,000 members it has become a model for how the Internet can effectively facilitate communication and the exchange of information among professionals around the world. ### << Previous Next >> [ View All Perspectives ] |
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