And, yet, the plans adopt the protocols, rule on whether patient care is in line with those protocols, and act as quality control managers. In combining the financing and delivery of health care, HMOs cannot claim that all they do is implement the benefits decisions of employers. If only because they can deny care, they are active in the delivery of care and are thus fiduciaries in their own right. Like physicians, the health plans have obligations based on medical ethics in decisions to provide or withhold care or to provide it one way rather than another. As ordinary business enterprises, they have obligations based on business ethics to deal squarely with their customers.
Regulation is needed to hold the health plans accountable for both sets of obligations.
The pressure for earnings imposed by the marketplace is unrelenting. If physicians are to assume significant financial risk for such things as the services of specialists and even the hospitalization of their patients, they may as well take on the full insurance function themselves. That way, they not only regain more lost autonomy, they cut out third-party administrative expense. This added advantage is far from assured, however. It depends on restraint in physician compensation, lest the nonprofit PSN become indistinguishable from the investor-owned HMO with which it competes.