Mr. Biggles is a 41-year-old who comes to the office having experienced abdominal cramping, diarrhea and flatulence for the past 24 hours. He returned from Indianapolis last night after two days at the Indy 500. Yesterday, he ate most of a bag of corn chips with Olestra, though not all at once, he says. "I also had some low-calorie potato chips. Barbecue. Great-tasting. No fat, either."
Dr. Beale examines Mr. Biggles. His blood pressure is 140/90. He is 5 feet, 7 inches tall, weighing 216 pounds. His abdomen is slightly tender and full, with borborygmi. His stool is hard and heme negative.
Fairness to others, or justice, is the moral basis for managed care. Aiming to improve the health of the population is what makes managed care morally defensible. No one patient is more important or worthy than any other. All patients deserve equitable care. Population-based health care means care to each according to his or her need and the needs of others.
Fairness and population-based care can evoke images from "The Lottery," of Marx or of the best-run managed care organizations. These pictures are all different. The true medical and ethical focus of managed care is to improve the health status of a population at risk in a cost-effective manner.
Has fairness changed? Do the haves have more and the have-nots less — or is the playing field more level now than when managed care first took root?
Stand up for fairness
The most important ethical principle in managed care should be fairness. But it is not — not yet, anyway.
As Emily Friedman has written, fairness has been left up to markets in managed care, and fairness does not matter a lot to markets. No market is going to worry that rural areas have trouble attracting physicians. Or that "distance medicine," with the potential to help improve physician productivity, seems even more remote when the server is downed by lightning. No market is going to care whether medically indigent inner city residents have a cost-effective primary prevention program or an outpatient mental health program.
Why has fairness become a market-mediated commodity? Because the American people have neither a solid feeling of community — geographic, spiritual, educational or occupational — nor a strong enough sense of interdependence to insist that everyone should receive a basic level of care. Instead of an equi-table system that assures an equal level of services to everyone, there is a hodgepodge of temporary alignments.
The hard and cold facts are that much of the death and disability in America comes from three behaviors: smoking, eating high-fat, low-fiber foods and remaining sedentary. One third of American deaths are directly related to one of these behaviors.
Quitting smoking, putting plant foods in the middle of the plate and integrating regular exercise are not only about personal responsibility. They are also about fairness to other managed care members who must bear the expense of others' dangerous and disease-breeding choices. Already, some physicians are paying, literally, for their patients who do not attend smoking cessation classes or have their cholesterol levels measured.
For physicians who want to practice fairness, the opportunity is a matter of profession: the chance to declare, aloud, a moral compass. Physicians must now show the leadership and vision that have not characterized medicine in the managed care era.
Every time an important issue of fairness has arisen, someone else has taken the lead on it. Only Drs. Koop and Kessler are visible on tobacco. No physicians are nationally visible leaders on obesity, substance abuse, child abuse, domestic violence or elder abuse. Clinical research, medical education and postgraduate training are similarly endangered for lack of physician advocacy.
These are medical issues, appropriated by nonmedical groups, that affect public health. With each issue goes a little bit of power, and with each bit of power goes a piece of what is important to medicine as a profession.
The profession's charge is to acknowledge and reiterate the interrelatedness of individual practices. One physician cannot practice well without the next. Physicians are not isolated free agents, justified in gaining for them-selves whatever they can without regard for others' interests. Becoming part of a group — even a medical professional group — is hard for some physicians, yet it is more necessary than ever; physicians remain independent of each other at their peril.
"It's the corn chips and the potato chips," Dr. Beale tells Mr. Biggles. "Make sure you drink eight to ten cups of water today and tomorrow. You need to eat two whole yellow or red vegetables every day, and a green leafy vegetable every day for at least a month. Also a multivitamin with D, E, A and K in it. Take this slip and let's measure your cholesterol. Come back next week and we'll discuss your tests and some ways to reduce your weight."
There is hope for justice in managed care if disease prevention, duty to others and social mission achieve a more prominent place at the managed care planning table.
What can clinicians do to promote fairness in managed care?
Become an expert on one preventive topic: vaccination, smoking cessation, physical fitness, weight management, alcoholism treatment, public safety, stress management, domestic violence prevention. Remember that every effort made to prevent illness improves your ability to provide for others and extends the available capitated resources.
Be prepared to work for incentives, not for salary. Some sacrifice will be required to keep physicians together as a profession and as collegial groups. Volume incentives without modification for disease severity are counterproductive. Positive incentives that are nonpunitive, that are proportionate to effort and that improve care quality are worthwhile.
Learn about legally established grievance and appeals rights, or advocates provided by consumer protection agencies or the state attorney general. Avoid litigation and arbitration, as these processes put most patients at a disadvantage. The poor, the powerless, the uneducated, the uninsured, the underinsured and the homebound elderly do not have access to an attorney or to the media. They will be squashed unless they know about and use their formal grievance and appeals rights.
John La Puma practices internal medicine at Alexian Brothers Medical Center in Elk Grove, Ill., and is a Chicago-based speaker and educator. Managed Care Ethics: A Guide to Decision Making in the New Era of Medicine, based in part on his columns for Managed Care, including this one, has just been published by Hatherleigh Press.