Mary Schweitzer

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Managed Health Care

When the term Health Management Organization (HMO) first appeared in the public lexicon, it had a very different meaning than it does today. The original concept, managed care, is precisely what we PWC's need. Imagine what it would be like. The patient would keep in close contact with a case manager personally knowledgeable about the totality of the patient's situation, who would help the patient put together the best possible package of health care, both broadly and traditionally defined. The case manager would serve as an aide to a primary care physician charged with providing basic preventative and chronic medicine care, yet equally aware of the need to refer patients to specialists for more complex problems.

Together the case manager and primary care physician would coordinate prescriptions and treatment plans as well as constant flows up updated information among all concerned medical personnel. Preventative and chronic care would receive the same attention that acute medical problems such as appendicitis have received in the past. Under the supervision of the general practitioner, the case manager would also coordinate the patient's needs for proper nutrition, community support, financial aid, and the availability of family or individual counseling as part of a complete package of health care. Does anyone still remember when this was the meaning of the phrase managed CARE?

It did not take long for corporate America to hijack the phrase to use as a euphemism for a far more sinister concept: managed COST. Managed cost with little attention to the patient's needs; managed cost with decision-making powers taken away from doctors and handed over to non-medical, poorly educated and overloaded bureaucrats; overt and implicit costs for seeking specialist-i.e., expert-analysis of a serious medical problem. What has been the result? As little as fifty cents out of every health care dollar actually goes to medical care. The administrative side of the process does not seem to come under the penny-pinching scrutiny that characterizes the provision of medical services to the client.

We find ourselves longing for the old standard of the family doctor with freely available, if expensive, access to specialists. Instead of introducing a higher level of public health care resting on increased knowledge of human ecology, we have a fast-growing industry driven not by an awareness of the precious national resource they are charged with protecting, but by an incessant chase for high profits, high executive salaries and benefits, low quality of service, competition through disinformation, and an army of immovable petty-minded bureaucrats. We're going to be a while recovering from the current managerial orgy of recklnessness and civic irresponsibility. How did we get here?

The quality and cost of medical insurance was under the control of state insurance boards for decades, creating a level of quality consumers took for granted. That changed when HMO's succeeded in convincing the courts that they were not insurance companies, and hence not subject to regulation by the states. Federal courts controlled by higher income white male political appointees took away the only mechanism consumers had for keeping quality healthcare within reach.

Disability insurance joined HMOs in hiding behind the shield of ERISA, a federal law intended to protect the worker from having his/her benefits stolen in a corporate takeover. Clients who had been mistreated or faced a broken contract could no longer simply file a complaint-now he/she faced an expensive and exhausting series of lawsuits and appeals in a federal courtroom ruled by appointed justices, without even the benefit of a jury of one's pears. Insurance companies and HMOs keep lawyers on salary and files of legal templates with which to argue their cases. There is little recourse for those who have been wronged by this system. And it has happened so quickly.

When the Clintons arrived in Washington in 1993, they made the growing national healthcare crisis a priority. They lost-badly. It is hard to remember that was only five years ago. In that time, freed of nearly all external constraints, and apparently bereft of internal moral restraint, the private market has created a monster.

There are two remedies: government-managed health care, or a strongly regulated federal healthcare market. Either would do a better job for the majority of American citizens. The first works well in Canada and Germany. The second, properly set up, would work as the old state insurance boards did: establishing a set of rules for this industry so they would return to their original mission of providing high quality services at the most efficient price.

Instead, the past five years have witnessed a breathtaking rush to innovate in all the wrong directions. Corporations that once took pride in serving the public now brag to stockholders about how many claims they turn down. Contracts have been replaced by glossy brochures containing only the information the marketing department wants the client to know. Insurance and healthcare dollars are wasted on billboards, television ads, sponsorship of sports arenas, even the purchase of skyboxes, all in the name of free enterprise. This is not the type of information that the public needs to make informed decisions.

The system increasingly caters toward those with the most resources- and those least in need of insurance protection. Economic studies provide the evidence with which to back up public suspicions: the higher the wage or salary, the better the benefits package. Those in the upper echelons have the opportunity to purchase blue ribbon health insurance plans enabling them to choose private physicians, whether general practitioners or spec ialists, at their own discretion.

There is nothing comparable available for the so-called part time working putting in 39 hours a week at McDonald's. And those of us rendered suddenly disabled too often find the only choice available is a short-run COBRA policy at an inaccessible price, or Medicare-IF you quality for it. Neither comes close to the healthcare packages available to America's highest paid executives. Something is very wrong when those of higher income not only have the option of a level of health care denied to those of lower income-but are offered that better quality of service at a price lower than the inferior healthcare packages available to low income workers and families.

All of this is not news to PWCs. But it was perhaps something that we didn't think about very much before our illnesses. And now-we do not have the connections, the energy, the coherence to enter the public disscourse and act to change the situation.

Banks are better regulated in the United States than health care-a sad state of affairs for this once-proud democracy. We need to ally with the disabled in general (who often must work part-time), with other victims of suddenly disabling long-term illnesses, with groups that speak for disenfranchised lower income households, and get the message to the public that they cannot continue to ignore the situation as we once did. Public health is a national resource. Opportunists and charlatans must not be permitted to destroy it.

Mary Schweitzer is an Assoc. Prof., Department of History, Villanova Univ. (on indefinite medical leave since January 1995 with CFIDS) President, WECAN Listowner, Sasyfras and Disinissues

© Mary Schweitzer, 1998

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