We may never know the identity of the public relations genius who decided that "downsizing," itself euphemistic, was too blunt a word to describe corporate layoffs. Presumably to assuage the readers of news releases and annual reports, he or she coined the replacement term "right-sizing," so that victims of the process might hear the sweet justice of their joblessness in the very verb that unemploys them.
No matter; physicians don't need the services of that same euphemizer to fix the problem with the "gatekeeper" image — its suggestion that people may sometimes find the gate shut. What primary care physicians need is a straightforward vocabulary for explaining to patients how managed care works, and the fact that, as Ethics columnist John La Puma, M.D., writes, "We too have to live within the rules."
In Managed Care's pages last June, Alan Hillman, M.D., of the University of Pennsylvania's Leonard Davis Institute of Health Economics called for physicians to explain to patients the financial incentives under which they work. We're happy to note that others have since echoed Hillman's call — and his denunciation of the so-called "gag" rules by which some plans limit physicians' ability to speak freely to patients. In a welcome step, the large HMO U.S. Healthcare (a future Aetna unit, it now appears) announced that it was replacing its analogous contract clause with one that requires secrecy only for "competitively sensitive information and confidential patient records."
How to be appropriately candid with patients about financial incentives — without scaring them or making them doubt that their health remains the top priority in care — is just one of the challenges primary care doctors face in a system whose designation remains stubbornly associated with the gate symbol you see on this month's cover. In this issue, we examine the gatekeeper system and some of the ways it is being revised and questioned. We hope you find the article useful.