John La Puma, M.D.

John La Puma, M.D.

Managed care has been faulted for a lot in medicine: the deepening cynicism of providers and consumers, the loss of control and choice in health care, the replacement of medical ethics with law, regulation and business ethics.

What managed care is designed to do, however, is cover all of us. Its central tenet is that by spending prudently, all Americans can have access to managed care. And many, though not all, do.

Those who do not have access are usually working full time, or at several part-time jobs. These jobs come without insurance. Employees get an hourly wage, and that's it. Restaurant and hotel workers — even full-time dishwashers and housekeepers — often have no work-related benefits.

Health care is too expensive for employers to offer, or simply not part of the way they do business.

Many recently graduated students also seem to be without access to managed care. Midwestern University outside of Chicago, for example, just graduated dozens of physician assistants — many of them still without jobs, and many of them definitely without health insurance. It ended upon graduation in May. The Kennedy-Kassebaum law apparently doesn't cover students who had health insurance through school up until graduation. So much for portability!

Still others without managed care access are homeless, unemployed and mentally ill. These are people who cannot find a managed care plan to save their soul, much less their diabetic foot ulcer. Why? Because most managed care plans only offer health care through employers, professional associations, alumni organizations or other large groups.

Why is this a problem? It isn't, for those of us whose jobs do not offer managed care but who belong to professional societies or who are members of alumni organizations. If we're lucky, one of these groups will offer a managed care plan to us. If we're not, they may offer only indemnity insurance.

Pitfalls of indemnity insurance

"Only" indemnity? Yes. For many people, indemnity insurance is inferior to managed care. Not because managed care's quality or service is better. Not because managed care's cost is lower, even though it is. Not because managed care's satisfaction is greater, because it is not.

Indemnity insurance is often inferior to managed care because insurance brokers want to sell products that are underwritten. They want to come to your house or office to tell you that their high priced, commercial indemnity insurance often excludes existing conditions. What is excluded? Conditions which require medication and ones which do not. How long? For a few months, a year, or maybe forever.

Imagine that! People who are actually sick actually needing insurance to pay for their urgently needed medical care. People who cannot put their diabetes or hypertension or colorectal cancer on hold until their indemnity insurance kicks in after 12 months. And these people — people without access to managed care — are always sicker than those with access to managed care.

According to the Robert Wood Johnson Foundation 1994 National Access to Care Study, whether you get medical care depends on whether you are insured. And insured, for most Americans, means managed care, not indemnity. Marc Berk and Claudia Schur write:

"Large and consistent differences among insurance groups are observed in ability to obtain a number of different health care services, the number of physician visits, and the likelihood of having a regular source of care."

Unhealthy workplaces

The true irony is that having managed care coverage depends on having a job that offers it. Are workplaces — the only places in which you can consistently buy managed care — healthful places to be?

Jobs that offer health benefits are, paradoxically, increasingly sedentary. And a sedentary activity level together with a high fat, low fiber diet is associated with more deaths in America than anything except tobacco use.

Fortunately, smoking is a thing of the past in many workplaces. California even made smoking illegal in bars and restaurants this year, though the law has been widely ignored. Smokers, chewers, dippers and spitters are now asked to step outside, though they sometimes disappear into the restroom instead. Outcasts with stained fingers and teeth who congregate near office side doors and in parking garages are obviously putting themselves at risk. But smoking's not the only way to lead an unhealthy lifestyle. What's going on inside?

Many people sit at their desks eight or more hours daily, getting up only to go to the vending machines or the restroom or the copying or fax machines. Cubicles of office space and workstation centers diminish privacy and autonomy, and increase stress. Many employees work in fear that they will be fired — not for cause but for restructuring, as companies figure out how to do more with less.

Food for thought

The most congenial workplaces often use food to celebrate birthdays and anniversaries, promotions and transfers. And the food of middle class America! Pizza shells laminated with cream cheese. Downy soft wheat rolls without a hint of grain. Yellow squash casserole with more butter than yellow squash. Tuna salad, stark white from mayonnaise. White rice and peas lubricated with salad oil. Mexican seven-layer dip that no self-respecting Mexican would come near. Bagels the size of Frisbees. All there for lunch. At your job.

Employment is most people's link to security. People can't sign up with managed care organizations on their own. Most plans are out of that business. It's too risky. Currently, only Humana offers HMO coverage to individuals in Chicago — not Blue Cross, not Aetna U.S. Healthcare, not others — and underwriting is part of the application.

What's a fair solution? Unhitch managed health care and employment. Will this be costly? Yes, but less so to the country than continuing to let its sickest go without managed care. Will it have other benefits? Yes. It may allow the safety net of professional judgment to stay intact.

Otherwise, the net risks larger holes, torn because of physicians' unanticipated, unresolved financial conflicts of interest. Though these holes could be mended with the help of other physicians, too few of us believe that our jobs could be next.

John La Puma practices internal medicine at Alexian Brothers Medical Center in Elk Grove, Ill., and is a Chicago-based speaker and educator.

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