TO THE EDITOR:
I am writing in response to the Address "Prometheus and Zeus: the Future of Orthopaedic Health Care" (77-A: 1295-1300, Sept. 1995), by Dick. The Greek analogy certainly is thought-provoking; however, it is incorrect. The battle is not between the old and the new. Insurance companies have been in existence for quite a long time, and they have constantly introduced new products to increase their profits. Managed care is currently a very successful product because it answers the need of business and government to cut the cost of health insurance. Patients initially enjoy the concept of managed care because it is not insurance; it is prepaid medical care. Managed care is analogous to automobile insurance that pays for maintenance. Managed care controls cost by negotiating discounted work in exchange for guaranteed volume. The managed-care provider extracts a fee in exchange for the service of matching patients with doctors. They limit their financial liability in two ways. First, to use the automobile insurance analogy, they arrange for discounted fees with only a number of garages. Second, they limit what they cover. For instance, they may cover oil changes and lube jobs, but you can have them only twice a year, with generic oil, even if you and your mechanic believe that you can prolong the life of your engine with three oil changes a year. They also do not cover major collisions and, in the fine print, it may say that they do not cover hood repairs and small dents in the door because they do not believe that they affect the function of your car. In fact, they are practicing automobile repair without a license. The mechanic is fully liable for any engine breakdown or apparent imperfections in the automobile despite his or her limited freedom to practice automobile repair as he or she sees fit. Because most people are not involved in automobile collisions, this type of automobile insurance would be very profitable for many years. As time goes on, however, more people may become disgruntled with the lack of service. Eventually, they will become angry with their mechanic. The greedy mechanic is the obvious cause of their maltreatment because their insurance company told them that they were fully covered.
This is the system that Dr. Dick states is here and that we must embrace. I disagree. As I stated, the battle is not between the old and the new. The battle is between our obligation to patients and the financial plans of a few chief executive officers. The number of patients who are maltreated, undertreated, and diagnosed late will no doubt increase as the financial pressure is increased. I believe that two real issues, morality and liability, need to be addressed in detail by the leaders of physician groups. Unlike a mechanic, we have a moral obligation to treat all of our patients to the best of our ability. Now, more than before, physicians are taking calculated risks. The chance of an abnormality is low, therefore a radiograph is not made. However, this not only leads to mistakes but also does not take into account what is often called the art of medicine. Many of us have made radiographs to relieve a patient's anxiety because he or she has a pain similar to that of his or her neighbor who was recently diagnosed with cancer. However, some managed-care providers cannot fit that into their algorithm. I was once told that we have an obligation to treat all of our patients as if they were our mother not our mother-in-law. We should do the best that we can, and when we have a question we should probe with the resources available. Managed care discourages this and, to a large extent, is at odds with our vocation.
The second issue is liability. We are liable for our patient's well-being as if we had access to all possible resources. Managed care has tied our hands, but they have done nothing to decrease our liability. Physicians have tried to decrease their liability with letters to managed-care companies stating why a test or procedure is necessary. This system cannot continue to exist.
I am aware that organizations are fighting for some changes, including an "any willing provider" provision. However, I believe that the members of the orthopaedic community who have the voices that can be heard should be the most vocal leaders against managed or rationed care. I believe that our professional organizations should concentrate their efforts on educating the public. Most managed-care companies have large advertising budgets that cloud the issues and mislead the public. Certainly, our efforts could not equal theirs but we should try to balance the scale so that the public can truly be educated consumers when choosing a health-care plan. Most patients are unaware of how managed care works and of the negative impact that it has on their health care. Time and money have been wasted lobbying the government to maintain the status quo. The status quo is no longer an option. However, we must educate the public and their employers regarding managed or, actually, rationed care for they are the ones who make the choices. I hope that Dr. Dick changes his attitude.
John Manta, M.D.: 7383 Eldorado Court, McLean, Virginia 22102.