By Sharon R. Kahn, Ph.D
This paper was inspired after sitting through a February 2001 symposium on managed care. SK.
Orwell observed that the steps leading down the road to totalitarianism are paved through distorting history and corrupting language. The new managed care readiness seminar offered at a public hospital recently fulfilled these prescriptions and even finessed the equation by ladling a pernicious dollop of shame induction into the usual Orwellian melange. The only difference between managed care and totalitarian regimes is that the former is doing is solely and strictly because of the money to be gained.
The seminar was co-led by two facilitators from the most prestigious accounting firm in the United States. The irony of two accounting consultants leading this class only lends complicity to their willingness to distort history.
The distortion of history and the induction of shame:
In Orwell’s novel of a totalitarianism, 1984, schoolchildren are taught that all capitalists wore black top hats and used the right of first night on poor women. Managed care readiness similarly distorts the history of service at public hospitals.
First on the agenda was to set a tone of shame induction. The idea was set forth and not ever challenged that the public hospitals had a policy which allowed staff to be rude, obnoxious, and contemptuous to patients in the past. Managed care would change this, as now patients’ have "choice." (Of this, more later). When was this ever a policy? Perhaps some overworked, understaffed personnel were brusque and impatient; however, how is this different from any private hospital? A few years back, before this writer had any insurance coverage, she too received care from the emergency room nearest her home. This hospital was a well-known and very prestigious facility, where celebrities, local politicians, and their families routinely received care and surgery. Despite their reputation for excellence, when I walked in a 4 a.m., the triage nurse was harassing a tearful elderly lady who had a history of heart problems and presented with chest pains, because her paperwork was filled out incorrectly. The woman’s daughter begged the triage nurse to get her mother help, as she was 80 years old and had previous heart surgery, only to have the triage nurse yell at her because her mother’s documentation was flawed. The nurse threw some more forms at the younger woman and left. I was the only other patient in the ER and I was ignored for several hours, until I resorted to some highly inappropriate behavior to expedite my case. The next day I sent off a letter of complaint to the hospital, detailing how this elderly woman was treated. Eventually, I received a form letter thanking me for using this hospital, and hoping I would chose to receive care again in the future at that facility. While what I witnessed would hardly be called usual care, the difference between private hospitals and our public facilities is that private hospitals have endowment monies and public relations flaks, while we received managed care readiness training which implied that the sort of care I received and witnessed at the private hospital was the usual treatment people received at public facilities prior to the ascent of managed care. We have all read about troubles incurred from surgeries gone bad at the most prestigious facilities. With their money and flaks, they can afford to negate the bad publicity with puff pieces about their new buildings and extended services. They can afford to have satisfied patients print up testimonials exulting to the public about the care received. There is much money can do that has little to do with medical treatment. Thus, by distorting history, these consultants burden hardworking staff with an extra lagniappe of shame.
The corruption of language
The next step, after the shame induction, is the corruption of language. Under managed care, we are informed that consumers (not patients) have a choice of providers (but not doctors). The reality of this is not proven. We have a choice of where we go for our weekend entertainment–which movie shall we see, or should we take in a concert. There is no choice in the usual sense of that word under managed care. One can choose doctors but what if they do not take that plan. One can start to see doctors under the plan, but perhaps they leave the plan. Perhaps one’s employer terminates the plan. Or perhaps the plan terminates one’s coverage. So much for continuity of care, choice, or personal control.
The reality is in most major cities, experienced physicians increasingly opt out of any insurance plans and will take only cash. This leaves the field to less experienced physicians. And as soon as they garner some experience–phit, they’re out and only taking money for services rendered. In the Midwest, where more physicians use MC plans, there is still little choice, as one mainly uses doctors nearest to one’s house. Rural areas remain the regions least afflicted with choice, as patients most travel far distances in order to see any doctor. Rural and semi-rural areas offer little attractions for educated, intellectual types. MC will not change this. Unlike the government, they will not offer incentives to physicians to practice there.
Money changes everything. The lack of funds prevents public hospitals from offering more services. The public hospitals cannot afford to pay staff anything comparable to the going rate at this time. At many public hospitals, the shortage of qualified staff is ludicrous. Consumers, patients, or staff hardly have a choice about this.
Sickness is different state from wellness. People who are truly ill enough to visit their physician cannot travel too far from their house. They only want to feel better—so they probably will little profit from psycho-educational planning at that juncture. Choice is not the first desire of the ailing. They want to feel better and to start this process by visiting competent physicians who are well-versed in their speciality at a facility nearest to one’s home. Being on a MC panel does not necessarily prevent people from being incompetent. And working for a public hospital does not make one a second-rate doctor.
Managed care is about "competition." There will no longer be colleagues. Instead, there will be competitors who are looking to get patients. Competitors are not like colleagues. Indeed, viewing professional activities through the managed care lens may mean derogating the merit of mentioning younger doctors and sharing information with peers. If others are potential competitors, we cast doubt on the efficacy of the treatment they rendered and try to persuade their patients to use us, as we, naturally, will provide superior treatment.
The term managed care offers another facet to the corruption of language. Managed care works like any other insurance. They collect fees and create profits through rationing or withholding services. The chief executive officers have enormous salaries. Stockholders reap enormous profits. Provided quality services would drive down the money available to the CEO czars. Certain populations are inherently unprofitable, such as those with chronic illnesses and the elderly: and those are the very populations whom managed care abandons first and leaves to the government. Medicaid and Medicare are wonderful insurance plans which offer almost total coverage and many services.
Managed care claims to offer a focus on primary care, with an emphasis on prevention. Yet most of them want their physicians to be productive, which means squeezing more patients into the time. Eventually, psycho-educational planning is extracted out, and pharmaceuticals are emphasized. For a host of complex and seemingly meritorious reasons, in the last 15 years, the FDA has eased the process of making drugs available to patients. Potions are rushed to market quicker and advertised widely. Then, a year or two later, severe side effects are discovered and the drug recalled or discontinued–ala phenfen. There was a similar brouhaha with a diabetes drug too. Additionally, pharmaceuticals considered "safe" are applied to a wider and more diverse population, with the negative effects disregarded.
Managed care ultimately causes an uptick in medical care expenses. For example, all ER’s have to "stabilize" severely ill patients, regardless of whether or not they take their insurance. However, once stabilized, they are transferred to a covering hospital. This disregards the fact that the transfer is an inherently de-stabilizing event which induces relapse. It causes stress neurotransmitters to flood the patient’s system. It introduces someone who is still histologically vulnerable to new pathogens. It disrupts "continuity of care." Thus, as many patients will relapse, it means the new treatment team has to again stabilize, which increases time, expense, and mortality rates.
Research and education are two other areas which are inherently unprofitable and immediately de-funded when MC takes over. Research is not always productive and does not always lead to profit-making products. Thus, we have a situation where the pharmaceutical companies are the ones funding medical research, and they have little incentive to fund areas which will lead to decreased use of prescription products.
At this point, the subversion of treatment into managed care’s theories seems inevitable. There is no will in the current political arena to investigate other possibilities. However, the inevitability of a managed care takeover does not mean we should passively accept their distortions of history and the corruptions of their language. If nothing else, perhaps this essay will encourage management of public hospitals to hire more respectful facilitators to ready staff for managed care.