John La Puma, M.D.
MANAGED CARE June 1997. ©1997 Stezzi Communications

John La Puma, M.D.

Managed care is doing its job. It has markedly reduced overtreatment and employer expenses for health care. It has forced efficiency where there was little, and pushed physicians to communicate better with each other and with their patients.

Managed care has also caused a lot of angst. Physicians and patients alike are angry about the conflict of interest that capitation represents. We are upset by disrupted relationships and threats to patient choice and trust, and worried that things will get worse before they get better. And that's just the lucky majority of us. More than 40 million people — 17.4 percent of the population under 65 — still have no health insurance at all.

Why does managed care look and feel so unfair?

Physician problems

For one thing, managed care does not make treatment easy for the treaters. In its most onerous incarnations, it micromanages access to specialists, CT scans and off-formulary medications. It competes on price, not on quality or service. It asks everyone to do more with less. It rations by administrative bureaucracy. It sacrifices convenience for capitation, and clinical judgment for negotiation jujitsu.

It switches the right place to send someone for a venogram from one year to the next. This afternoon A1 Analyses does most of your radiologic tests; next month Z3 Diagnostics does them.

It prizes excellent management over excellent clinicianship, and makes physicians worker bees, something many of us chose not to be in choosing medicine.

It forces a 76-year-old woman on five medications and with four diseases into a three-minute exam on the second visit, because the first was consumed by paper work.

It discourages probing into the details of a twinge of chest pain or ankle swelling, mentioned in the visit's last moment, for fear that more physical examination and a time-consuming cardiogram will be needed.

Yet no physician wants to practice medicine in constant fear of learning more than he or she will have time to act upon.

Physicians want to care for the medically indigent, to educate students and trainees and to research scientific problems. Managed care has not held up its end in these areas, either. Responsibility for the medically indigent has been deferred to the county hospital, usually indigent itself. Medical research is left to universities in most cases. Postgraduate education? Internships routinely prove to be money-losers in an outpatient setting, but some managed care organizations will participate in residency training if trainees make a three-year commitment.

Physician solutions

Most physicians have put their blood, sweat and tears into learning medicine. Many of us have great skill now, but use it in only one way — office and hospital practice.

Ironically, managed care has offered a hidden blessing for physicians because its very pressures have pushed many of us to explore less stressful pursuits. More than ever, physicians must take a hint from other workers and learn new skills — or find new applications for our medical knowledge.

If you have even an inkling of interest in leadership, public health, research, writing, or righting the legal world, your help is both needed and compensable, and your contribution can be a creative one.

Few doctors run antique stores or cook in restaurants, and few will. Those who will will do so for love, not for money. If you have a passion like this, follow it — even if at nights or on weekends — before it is too late.

Patient problems

Patients, too, have developed strong feelings about managed care. So strong they've complained loudly to reporters and legislators all over, and suddenly a raft of new laws have been passed, with scores more in the offing. Many of these laws tell doctors and plans how long to hospitalize patients with particular conditions.

Patients want this protection from managed care, even if it is onerous to physicians. Newsweek, Time, web sites galore, every major newspaper and nightly television feature the Scrooge-like qualities of some health plans. Some of this coverage is well deserved, and many Medicare and Medicaid patients are in for a big, unwelcome surprise when they switch, or are switched, to a managed care plan.

However, patients also want to pay less. Too many patients have no idea how much their care really costs, and the cost of care has in effect been proved to be too high for the growing numbers of Americans who have slipped out of the formal health care system. Increasingly, persons with full-time jobs are not offered health insurance, either because the company can't afford it or because its first loyalty is to shareholders rather than employees. Every dime not spent on health care is a dime available for dividends or for short- or long-term distributions.

For those patients who do have access, managed care is usually affordable care, and everyone from employers to employee to the unemployed wants that. Ethics is important, but people really get heated about money.


We are living in an economic environment in which the stock market has headed north at breakneck speed for years, but the average worker's take-home pay has been stagnant. Health care is employer-based, and just like every worker's job, health care is not secure.

Managed care looks and feels unfair because its promise — that by spending prudently on most of us, we can bring all Americans under the tent of equal access and thus make health care secure — is unfulfilled.

But if physicians and patients can trust one another again, a healing, mutually accountable doctor-patient relationship is worth rebuilding, because when push comes to shove, clinicians are the ones who can help. Catching enough of a glimpse of a screaming infant's croupy throat, finding new jar grips for an arthritic grandmother, holding the gaze of a smoker worried by the new shadow on his radiograph — these moments help patients, and often we are the only ones who know.

We have one sure way to revitalize the power of medicine and to help patients who need it. We start by emphasizing accountability and service, and making our best clinical judgments, one patient at a time.

John La Puma, M.D., practices internal medicine with Alexian Brothers Medical Center in Elk Grove, Ill., and is a Chicago-based speaker and educator. With David Schiedermayer, he is co-author of The McGraw-Hill Pocket Guide to Managed Care: Business, Practice, Law, Ethics (McGraw-Hill, New York, 1996).

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