Through the mid-eighties and early nineties, medical price inflation exceeded the consumer price index by six or seven points. As Americans we spend the greatest percentage of GDP on health care and simultaneously have the highest rate of uninsured and underinsured citizens of any industrial nation. Congressional action under the leadership of Chairman Bilirakis has made serious inroads into reducing infant mortality, yet we still have the highest infant mortality rate of any industrial nation. Any discussion of the ethical dimensions of the patient- physician relationship must begin with a recognition that over 40 million Americans are not able to access a relationship with a physician beyond the emergency room. While the moral high ground of the Hippocratic principles focusing on individual patient advocacy by physicians is usually stated as the starting point of any ethical discussion of health care, in fact, the patient- physician relationship must be understood within the demands of justice.
Access is a first order obligation which remains unfulfilled.
As health insurance premiums, which are paid through taxes or forgone income of working Americans, ate up an increasing amount of public and private budgets, employers moved aggressively to incent employees to select managed care plans because of managed care's lower and predictable costs and definable, high quality. By the early nineties, large regional markets such as Los Angeles, San Francisco, Minneapolis and Boston saw managed care emerge as the dominant health care finance and delivery model. The patient-physician relationship, traditionally the focus of bioethics, is situated in a set of relationships and structures determined by the evolution of health care finance and delivery. The health care system is evolving from the medical guild model to prepaid, organized care systems accountable to institutional purchasers. The notion of a physician operating as an autonomous craftsmen in the medical guild has given way to the demands of purchasers to rationalize the continuum of medical care through industrial or systematic models in ways which can measure and assure consumer and patient value.