Byline: Dr. Joel Karlin
Over the last two years we have seen a flurry of anti-managed care legislation introduced in both Congress and state legislatures all over this country.
Recently, the president received recommendations from a blue-ribbon commission, which he appointed to create a Patients' Bill of Rights in managed care. A recent Rocky Mountain News editorial questioned the advisability of implementing those suggestions into law, and proposed instead to give individuals the right to select their health insurance. As a practicing physician for 23 years, I have seen both the good and bad of managed care. The goals of managed care are laudable: maximize quality and patient service and minimize the total cost per patient per year. The problem is that no health plan has been able to achieve all of these goals.
Among those health plans that have received the highest grades in patient satisfaction - as Rocky Mountain HMO did in a recently published patient survey by the Colorado Business Group on Health - their premiums have not been low enough to achieve high market share.
Among those health plans that have purchased market share with low premiums, often selling in certain markets below their cost to provide care, quality and service have suffered.
So what's the answer? Listen to some CEOs of health maintenance organizations and they will call for less government and praise the ability of the ``free market'' to change what health plans do. But if the free market works so well, why has it become necessary for the managed-care industry to come forth with programs like ``Put Patients First'' and ``The Code of Ethics in Managed Care''? Listen to the horror stories of patients and physicians who have been negatively impacted by ``tightly managed'' managed care, and they would have the government regulate everything managed care does.
The long-term answer is neither of the above options. First, we must admit that there is no single delivery system or health plan that works for everyone. Different people have different needs.
Second, we must recognize the limitations of our current employer-based health insurance system and make the necessary changes to accommodate those differing needs.
Since the overwhelming majority of people obtain health insurance through their place of employment, the financial impact of providing such insurance weighs heavily on the employer. The employer's answer, increasingly, has been to limit employees' choice of plans, often seeking the lowest-cost, most tightly managed HMO.
Here lies the tragic conflict. The employer tries to manage the cost of providing health insurance to employees, while the employee may not be able to choose his desired health-care delivery system, let alone health plan or physician. So much for allowing free market forces to change how health plans treat patients.
Today, the employee loses the employer's contribution for health insurance if the employee does not accept the employer's selection. And the employer loses the beneficial tax treatment if the employee should take that contribution and purchase insurance away from the workplace.
The Colorado Medical Society and American Medical Association believe there will be greater value and efficiency by involving patients more directly in their own health care. Several successful models exist currently in both the public sector (the Federal Employees Health Benefit Plan) and the private sector. By making patients into true ``health-care consumers'' market forces can better help restrain prices and improve the quality of care delivered.
In such a system, individuals would select the delivery system and health plan that best meet their needs and the needs of their family. Federal legislation would be required to provide the employer with the same tax treatment for voluntary payment of health insurance premiums whether the employer provides the health insurance plan for the employee or whether the employer provides a financial contribution to the employee, which could only be used to purchase individually selected and individually owned health insurance. Group purchasing co-ops, a more competitive individual insurance market and medical savings accounts could be the purchasing vehicles.
In such a system, cost, quality and access would determine the winners. No longer would government be asked to intervene. Health plans would become more responsive to individual patient needs or lose market share - both acceptable outcomes.
The Colorado AMA delegation has recently been successful in creating such AMA policy. Look for a bill to be introduced in Congress late next year.
