A managed care organization serves a defined population with limited resources in an integrated system of care. Thus, a single organization may both provide and pay for care. Organizations as providers have duties such as competence, skill, and fidelity to sick members. Organizations as payers have duties of stewardship and justice that can conflict with provider duties. Managed care organizations thus have conflicting roles and conflicting accountability.
An organization's accountability to its member population and to individual members has a series of inherent conflicts. Is the organization's primary accountability to its owners, to employer purchasers, to its population of members, or to individual, sick members? If these constituents somehow share the accountability, how are conflicting interests resolved or balanced? For example, the use of the primary care clinician to coordinate or restrain access to other services involves the primary care clinician in accountability for resource use as well as for care of individual patients. Although unrestricted advocacy for all patients is never really achievable, the proper balance and the principles of balancing between accountability to individual patients, a population of patients, or an organization need to be made explicit and to be negotiated in new ways.32–34
Does paying physicians by salary, capitation, risk withholds, or bonuses, with a variety of incentives to withhold (more or less) needed care from patients, represent a conflict of interest for physicians and violate the fiduciary nature of the relationship? All mechanisms for paying physicians, including fee-for-service reimbursement, create financial incentives to practice medicine in certain ways. We still lack a calculus to minimize or even describe in fine detail how such conflicts affect our ability to justify trusting relationships. Even-handed social attention seems appropriate to all the different mechanisms of payment. Balanced assessment of how the details of remuneration systems influence doctor's willingness to act on behalf of patients will best protect both the health of the public and the health of doctor–patient relationships. This is a priority for a new form of empirical, ethical research.
“Whose doctor is it anyway?” expresses one of the most critical problems inherent in managed care for the doctor–patient relationship. Patients correctly wonder if doctors are caring for them, the plan, or their own jobs or incomes (the latter is equally problematic in fee-for-service care). This ambiguity erodes trust, promotes adversarial relationships, and inhibits patient–centered care. The recent controversy over gag rules has only confirmed this set of fears in the mind of the public which is now seeking regulation of the managed care industry through the political process. As illustrated in , the interests of patients, plans, and doctors can overlap to a greater or lesser extent. Professional ethics dictate that physicians attempt, as individuals and as a profession, to ensure that their interests and those of their patients are congruent in clinical practice. Plan interests, however, can pull physicians away from this goal, as the organization's values and their implementation inevitably influence attitudes, behavior, and experiences. Alternatively, plans could promote patient-centered care by trying to maximize the extent to which patient, doctor, and plan interests overlap. For example, promoting continuity, communication, and prevention can further all three interests so long as value (and not cost alone) is seen as the plan's product. Similarly, resource stewardship can be honestly promoted as a way to ensure that quality care is available for future patients.
Figure 1 Overlapping and conflicting interests. The interests of patients (top circle), doctors (left circle), and health plans (right circle) may overlap to a greater or lesser degree, depending on the actors and the circumstances. Employers' interests are likely (more ...)
Another feature of managed care organizations is their emphasis, in principle, on primary care. They often rely on primary care clinicians to manage, coordinate, or restrain access to other services. Members are required to choose or are assigned a primary care physician. With the primary care emphasis comes an opportunity for the development of strong relationships between primary care doctors and their patients. In addition, new relationships with patients who in the past never sought care and seldom entered into a doctor–patient relationship may be more likely in a system that emphasizes wellness and primary care, although this may be more apparent than real. It is unclear at present how a “relationship” between a primary care physician and a member of the physician's panel, who have never met, should be characterized, or what responsibilities are associated with it. It is not yet demonstrated that an emphasis, in principle, on primary care leads to stronger relationships, and to what extent countervailing forces such as lack of continuity counter this.
Integrated systems, characteristic of most managed care plans, introduce opportunities for improvement in continuity across the spectrum of care. For example, opportunities arise for case management or for coordinating care between doctors' offices, hospitals, nursing homes, and home care so that individuals do not fall through the cracks of a fragmented system. With integration come new responsibilities for doctors and other health care practitioners for communication, teamwork, and a more longitudinal approach to patient care. This continuity may be thwarted, however, by turnover in staff or members.
Standardization of practice, sometimes relying on “evidence–based medicine,” is often used by managed care to minimize costs or maximize or ensure quality of care. Standardization is often touted as promoting fairness by treating like individuals in like manner. Both standardization and the application of evidence-based principles in choosing care standards, however, rely on value judgments about what counts as good evidence and how that evidence should be interpreted and applied. The danger to the doctor–patient relationship in these movements is that individual patients with their individual needs and preferences may be considered secondary to following practice guidelines, adherence to which may form part of an evaluation measure of physician's performance. Using practice guidelines and the “standard of care” to determine which benefits are covered, and for whom, ignores the incredible variation in patient preferences and characteristics. This approach treats the disease without reference to the illness.35
Rather than treating individuals with similar illnesses in like manner, the result is that individuals who merely have the same disease are treated in like manner. Fairness is sacrificed to uniformity.36
Reliance on “data” may discount the patient's own story, thus discounting specific evidence about personal aspects of disease and its meaning and value. Obviously, discounting the person depreciates the relationship.
Continuous quality improvement and total quality management are industrial strategies37
lately applied in the health care arena. Although quality improvement efforts are by no means unique to managed care organizations (MCOs) in the health care industry, a few individual MCOs and the American Association of Health Plans have been leaders in promoting quality initiatives and include them in the accreditation process. Implementing continuous quality improvement may work for
the doctor–patient relationship by enhancing competence and the perception of competence, or it may work against
the doctor–patient relationship if it diminishes practitioner flexibility or accountability, or if it is perceived by practitioners as a manifestation of distrust by the organization.
The effort to cut costs to increase competitiveness or profit means having doctors be more “productive” by seeing patients faster. The first thing dropped as visit length shortens is psychosocial discussion.38
So far, the average length of visits in the United States does not seem to have dropped significantly, probably because of inherent inefficiencies in scheduling and doctors' abilities to finagle time to fit the needs of patients.39
Yet both patients and doctors feel a heightened sense of time pressure, and patients worry about being on a conveyor belt with a production-line-oriented doctor. As companies attempt to increase providers' efficiency, these fears will be realized unless thwarted by consumers, professionals, or more visionary organizations. Less time, otherwise, will mean less relating time and damage to care: less-accurate and incomplete data; difficulty in identifying the real problems; less efficiency in test and treatment choices based on knowledge of the individual patient; less trust; less healing; more errors and more waste.39
A penny of good communication time may avert a pound of unnecessary or even harmful spending used to reassure an anxious patient or substitute for a sketchy history.
We believe that in the long run the trust of the public that the physician is doing the absolute best for the patient must be maintained so that the doctor–patient relationship preserves its healing functions. At the moment, the momentum of control is such that industry and corporate leaders have the upper hand and care is or will suffer as a result. Only if consumers and the medical profession stand together and insist on standards that protect the doctor–patient relationship will it endure the acid raining against its delicate face.