MANAGED HEALTH CARE— with its alphabet soup of HMOS, PPOS and MCOS-has broken the back of medical inflation as Americans get used to concepts such as primary-care physicians and intense financial scrutiny over procedures and surgeries.
Nearly everyone agrees that managed health care has tamed the monster of health care costs which threatened to gobble up American businesses perplexed by huge employee insurance costs in the '80s. But, as stories come out of medical horrors such as drive-by mastectomies and patients who died because they were denied expensive care ruled out by their insurance providers, the question arises: What is the social cost of those savings?
That question will be scrutinized by The Woodstock Theological Center at Jesuit-operated Georgetown University. A $270,000 grant from the Robert Wood Johnson Foundation-the nation's largest philanthropy devoted to health care—will enable the center to bring together ethicists, physicians, consumers and health insurance officials to thrash out issues involving American health care in the late 20th century.
”I don't presume to be an answer man on this,” said Jesuit Father James Connor, director of the Woodstock Center, a research institute sponsored by the Jesuits to address business and social ethics. He noted that health care issues are complex and involve balancing a variety of legitimate interests.
The format of the study is a simple one; some 40 leaders in the health care arena will come together for regular, no-holds-barred, confidential discussions on the ethical issues in health care today. After two years, the center plans to bring out a checklist of moral concerns which need to be addressed by all parties in today's complicated health-care universe.
The format is based upon similar studies that the Woodstock Center has conducted on business ethics in the past, including “Ethical Considerations in the Business It's worked in the past and I just hope and pray it will work in the future,”said Connor, who plans to moderate the discussions.
While many of the issues in health care might seem obvious to anyone who reads the papers or goes to a doctor, Connor insisted that the Woodstock Center has no pre-existing agenda for the study. “I have no ax to grind,” he said. “We'll get the people involved to bring the issues to the surface.”
Connor, a theologian and former pastor at Holy Trinity Church in Washington, D.C., said that the format grew out of his own experience at his former parish, a magnet for Washington-area Catholic professionals. There, he said, a major concern was “about what it means to be a Christian in the marketplace.” The result was the establishment of parish-based discussion groups focused on ethical issues in the workplace.
J. Michael Stebbins, a theologian and former nurse now working as a senior fellow at the Woodstock Center, noted that there is widespread concern that managed health care is beginning to resemble rationing of care, the specter of which helped to doom President Bill Clinton's health care plan proposed early in his first term.
Among health-care providers, Stebbins said, “there is a temptation to act like a corporation which wants to limit its financial risk.”
Stebbins, who wrote the proposal which brought in the grant for the project, expects the study to generate widespread interest. “Everyone is a consumer of health care. More and more people are having experiences that aren't so positive,” he said.
Jesuit Father William Byron, an ethicist at Georgetown University and member of the steering committee for the project, noted that while consumers may be grumbling, there is also widespread revolt among doctors, many of whom have retired in recent years rather than face the widespread changes in health care developed during the past decade.
”There is a big issue of who is practicing medicine; the insurance companies or physicians?” Byron, the former president of The Catholic University of America, said. In a recent article on health care issues in the Jesuit magazine America, Byron noted that physicians “complain that they are overworked and underpaid by the so-called successful or cost-effective managed care companies.”
Those complaints transfer to problems faced by consumers, particularly with women patients, noted Connor. “Women will tell me that they want to go to doctors and tell their stories. They want the doctor to spend some time reviewing their situation. They don't want to be treated like a car on an assembly line,” he said.
However, that concern works against the situation faced by many doctors who are told by insurance providers that they will only be paid for 15 minutes per patient, a stipulation which encourages the assembly-line mentality.
Other complaints from doctors that have an impact on patient care include:
• Insurance guidelines that tell physicians what particular treatment will be covered for a condition, even if the doctor's judgment calls for another kind of treatment. “I don't want an accountant 3,000 miles away telling me what I should do,” is a regular complaint of doctors, said Connor.
• Doctors who are paid for each patient, no matter what kind of treatment they might need. The result is that chronically-ill patients are not financially valuable to doctors and health care providers
• “Gag rules” imposed on doctors who are unable to discuss with their patients the impact that insurance regulations will have on treatment decisions. Some arrangements prohibit doctors from telling patients what non-covered procedures could be useful in treating their condition, a prohibition which some see as a violation of the physician's Hippocratic Oath.
• The impact of changes in the delivery system on care for the poor. Previously, physicians and hospitals could subsidize treatment of non-payers through shifting costs. “But you can't do that anymore. The system has cut out all surplus,” noted Connor, who added that the changes come at a time when government is cutting back on medical assistance to poor people. One recent study of New York residents indicates that the number of uninsured-largely people who are working but don't have access to health insurance through their jobs-has increased from 20 percent to nearly 25 percent in the past five years.
While the bogeyman in these complaints appears to be the managed care companies, Connor cautioned that an adjustment in health care was needed. “Costs were going out of sight. Something needed to be done,” he said. He argued that the managed health-care revolution has produced a stronger emphasis on preventive care, including diet, exercise and other low-cost treatments which combine good medical care with financial prudence.
The Woodstock study probably won't result in a giant list of recommendations to revamp the American health care system, Stebbins said. The vision of the study is a much narrower one.
”At the end there will be a concrete checklist which people in the industry can use to think through the critical issues. Not recommendations, but questions,” he said, noting that the study will not provide a blueprint but more of an ethical “pilot's checklist” to assure that the proper questions have been addressed by all concerned.
Peter Feuerherd is based in New York.