If my wife or children become sick, I want the best possible medical care for them. I might even like the same for myself. We all would. But if all of us can get whatever health care we–or our doctors–want, then society will ultimately be worse off. Growing health costs will progressively prevent us from spending much more on anything else. This is the dilemma of a nation obsessed with individual well-being that must also protect its collective well-being. We barely acknowledge it.
The latest health debate involves the patients’ “bill of rights,” a phrase adopted by both Democrats and Republicans. The common language is significant. It panders (as politicians love to do) to the popular belief that we can avoid messy ethical, political and economic choices simply by legislating an appealing list of patients’ “rights.” It isn’t that easy. Unless someone can say “no” to health spending that might be futile, unnecessary or self-indulgent, costs will spin out of control.
If boundaries between wise and unwise treatment were always clear, there would be little controversy or confusion. But typically, they aren’t. What may seem hopeless surgery to some distant analyst may seem–if it’s my son or mother–imperative to me. There’s an unavoidable collision between our personal instincts and society’s wider interest in ensuring that health spending significantly improves people’s health. Anyone playing “gatekeeper” (that is, making the decisions) courts unpopularity.
In recent years, the job has fallen increasingly to “managed care.” The patients’ “bill of rights” reflects an alleged backlash against this. We’ve all heard the stories: Emergency room coverage denied because advance approval wasn’t obtained; patients barred from specialists they–or their doctors–want; people hustled out of hospitals while they still seem sick. Managed care often seems pitiless and incompetent. Sometimes the stigma is deserved; as often, it’s exaggerated.
People imagine the worst from managed care; they usually don’t experience it. Most Americans rate their health care favorably: 66 percent of those in managed care compared with 76 percent in “fee for service” medicine, finds a survey for the Kaiser Family Foundation. The Kaiser survey documents fears that coverage might be denied but also finds that the fears reflect “rare events that seem threatening,” reports the journal Health Affairs.
It’s also a myth that the main obstacle to good care is some callous managed-care accountant. Studies may someday show that managed care has pervasively lowered quality. For now, though, the more common threats arise from mistakes by nurses, doctors and hospitals. A presidential commission on health-care quality found widespread “overutilization of services, underutilization of services, and errors.”
All these problems predate managed care’s huge expansion in the 1990s. One 1988 study of deaths from stroke, pneumonia and heart attack in 12 hospitals “indicated that 14 percent could have been prevented (with) adequate diagnosis and treatment,” said the commission.
Just because doctors, in good conscience, recommend a given treatment doesn’t mean it’s always needed. Many studies have shown that patients with similar conditions often receive different treatments–some far more costly than others–with little difference in results. The promise of managed care is to promote the “best practices” by emphasizing what’s effective and eliminating what’s not; the danger is that, under the guise of doing this, it will deny or delay sensible care.
The patients’ “rights” debate skirts these practical problems and instead treats managed care as an all-purpose ogre that is defeating the promise of modern medicine. Lost in all the rhetoric are two important realities.
First, the backlash against managed care is most powerful among doctors, not patients. It is doctors whose independence and incomes are most threatened. Their decisions are reviewed and sometimes reversed. In negotiations, their fees are squeezed. Between 1992 and 1994, doctors’ average incomes stagnated at $182,000, though they later rose to $199,000 in 1996.
Second, managed care has controlled health costs. Between 1965 and 1990, health spending rose about 11 percent annually. The increases defied government and voluntary controls. One reason is that doctors and hospitals had an economic interest to order as much care as possible. But since 1995, increases have averaged 3 percent to 4 percent. Subdued health costs have helped lower inflation and raise wages.
All this suggests caution in new legislation. Some standards are needed, because some managed care groups are worse than others. There should be quick appeals of adverse coverage decisions. “Prudent” use of emergency rooms should be protected. But more sweeping proposals–embodied mainly in Democratic plans–could cripple cost control. These might improve doctors’ incomes more than patients’ health.
Whatever happens, patients’ “rights” will remain elusive. Medicine is the most personal of services, yet its promise makes it ever-more technological, bureaucratic and costly. The dilemmas ensure many deceptive debates and disappointing “reforms.”