It's a problem, all right. Patients aren't just complaining any more. As forgotten players in what all too often seems to be a tug of war in many directions, patients — the ultimate consumers of health care, are making their presence felt.
A few years ago they might simply have groused about being denied a referral or being booted from the hospital sooner than they and their physicians thought proper, but more and more they are exerting their power in the courts, with their employers and, most publicly, with Congress and state legislators. Senior Editor Frank Diamond covers these and other aspects of this sea of change in our cover story.
Managed care is partly responsible for this turn of events. It had a mandate: Control costs. It did some obvious stuff, like utilization review and generic substitution. In most cases this didn't result in harm, and some had benefit beyond cost control (some unneeded procedures weren't performed, for example, sparing patients the dangers associated with surgery and/or hospital stays). But, insulated because their employers paid most of premiums, patients only noticed the clinical controls.
Americans across the board are being forced to be self-reliant. Pensions have given way to 401(k) and other self-directed investment plans; welfare recipients are cut from the rolls after a period; few now believe their jobs are permanent.
Health benefits and costs are broad civic issues. Though patients deserve more control over their care and coverage, uncontrolled access to specialists would raise costs needlessly when the more conservative approach — ensuring access, at a price, to a plan that features uncontrolled access — is just as fair to the individual, and better for society. Lawyers, specialists, and others who say they are on patients' side stand to benefit most from the lavish spending managed care resists. Legislatively, consumers and these "allies" quickly have accumulated a great deal of power. May they use it wisely.