April 1996 Bulletin

Urges managed care to put patient before profit

by John J. Gartland, MD

John J. Gartland, MD, is the James Edwards Professor, emeritus, orthopaedic surgery, Jefferson Medical College of Thomas Jefferson University, Philadelphia. Dr. Gartland is the 1979 past president of the Academy.

Physicians practice in an environment clouded by conflicts between themselves and those paying the health care bills, and one that reverberates with demands for the profession to take back control of the health care delivery system. Problems with most of the proposed solutions become apparent when it is recognized that, conceptually, this environment contains two separate but closely related segments: health care and health care delivery.

While retaining professional control of health care, we have lost professional control of the health care delivery system, and little chance exists of changing that reality. Our loss of control began when Congress legislated the Medicare and Medicaid programs in 1965, and was accelerated by the burgeoning private health insurance market that followed.

Recent pressure from the public and others to not only constrain health care costs, but also to modify the type of health care available further lessened professional control of the health care delivery system. These pressures stimulated the private sector to champion managed care, and a competitive evolving managed care market soon followed.

With failure of health care reform in 1994, managed care and HMOs have become the national health policy by default. Considering health care a commodity, the health care delivery system is now shaped by a commercialized and competitive marketplace. Unfortunately, the principal casualty of our loss of influence on the health care delivery system is the patient.

Health care is now both a profession and a business and, while it probably will remain so, our concerns should not concentrate solely on the economic side. We retain professional control of the health care segment of the practice environment, and it remains our obligation to insure that the qualities of humanism, caring and ethical behavior, the core of our professionalism, never diminish.

As orthopaedic surgeons, our primary responsibility remains the healing of the sick and the injured. In the final analysis, true health care is really a local issue where the quality is determined between individual physicians and their patients. However, a major concern about this new health care marketplace should be the bad effect managed care could have on the physician-patient relationship. The most basic problem with medical care that is aggressively managed according to cost is that success for the enterprise is defined by placing considerations other than patient welfare between physicians and patients, considerations such as conflicts between the continued need to improve services and operations and the continued need to return profits to investors.

Managed care is neither inherently bad nor inherently good in concept but, because publicly-traded HMOs are a powerful economic force, safeguards are needed to ensure fair treatment of patients and physicians. So far, only 22 of the nation's more than 600 HMOs are publicly-traded, but these few account for 40 percent of HMO enrollment, have amassed astonishing capital reserves and return profits to investors by virtue of limiting both access and physician choice to their subscribers and by cutting provider incomes.

In this country, society regards health care as a right of citizenship. Two questions beg to be addressed: 1. does this right extend to managed care firms to amass outrageous fortunes from patients exercising their own right to health care?, and 2. is the public's right to health care adversely affected by managed care policies that encourage underuse of health care services as corporate decisions to increase profits?

If managed care is to be our national health policy, it must be restructured to benefit patients, not corporate executives and investors, and that will require collective action by physician and patient advocacy groups to spur legislative action.1

The Robert Wood Johnson Foundation has shown that coalitions, or broad-based, loose-knit networks of organizations that come together to address specific issues, are the most promising way to tackle today's complex public health problems.2 Waiving its normal conservatism for the common good, the Academy should initiate the effort to form such a coalition with other medical organizations and broad-based patient advocacy groups. The purpose of this coalition would be to convince Congress that managed care plans will have a positive effect on health care in this country only if they are restructured to put patient health outcomes before their own financial interests.

Physicians and their patients must insist that managed care plans be designed to deliver appropriate health care to citizens of this country, and not designed to profit corporate executives and investors.


  1. Eisenberg L: Medicine-molecular, monetary or more than both? JAMA 1965;274(4):331-334.
  2. Coalitions: efficient, effective agents for social change. Advances, the
    national newsletter of the Robert Wood Johnson Foundation. Spring 1995;Vol.VIII,No.2:1-2.

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