Informed Consent Meets Managed Care

Informed consent is considered an essential element of the helping process, carrying with it connotations of honesty, trust, and mutuality in the serious business of making health care decisions. Having been shaped by legal, clinical, and ethical doctrines, informed consent is based on the presumption of choice - that providers have the ability to inform patients about their options and that patients have the capacity to accept or decline various alternatives without coercion. In contrast, managed care, the dominant form of health and mental health care delivery, bases its success on the constriction of choice - limiting the pool of providers through impaneling, using "best practices" to narrow clinical options, and using gatekeepers and other forms of utilization review to efficiently channel the flow of patients. Managed care not only presents new challenges for the proper execution of informed consent but also increases the amount of information about which consent must be given. This article examines three core elements of informed consent - understanding, voluntariness, and disclosure - as they are shaped by managed care and describes options for overcoming the barriers to genuine informed consent. MANAGED CARE There are, it seems, as many definitions for managed care as there are manifestations of it. In essence, though, the term is what it says it is - the management (through a variety of functions) of care (including health, mental health, and social services). Such "care management" occurs through a variety of methods. It can be accomplished structurally, for example, through health maintenance organizations (HMOs), where the spectrum of care for a particular population is provided within a fixed prepaid budget. Care is also managed through policies that encourage providers to use services judiciously - by paying them on a capitation basis rather than by fee for service, by promising a flow of referrals for discounted rates, by rewarding efficient use of services through bonuses or by punishing overuse through salary "withholds" or deselection from panels. Policies are also structured to encourage service recipients to be more cautious in their service use by limiting reimbursement to certain classes or panels of providers, by funneling access to specialists through physician gatekeepers, by penalizing inappropriate use of "high end" care such as emergency rooms, and by limiting access to costlier medications or procedures. Through these and other methods, managed care controls access to care and in doing so controls costs. The buyers of health care - employers, individuals, and state and federal governments - put a premium on cost containment and predictability following unprecedented growth in health care expenses through the 1980s. In part the escalating costs were attributed to a fee-for-service system that rewarded excess service use and the fact that consumer behavior with regard to health care differs from that with other products and services. Because the users of health care and the purchasers of it are not necessarily the same and because of the way health services have been marketed, consumers had little incentive or ability to "comparison shop" on quality or price (Public Agenda Foundation, 1994). The insertion of managed care into the health care buyer-user equation was designed to alter that process. A third party that could negotiate rates, assess quality, and promote efficiency would save the system from cost increases that could not be sustained. By the measure of cost containment, managed care has been reasonably successful. In psychiatric care, both inpatient days and length of stay have been substantially reduced (Schreter, 1993), and in 1996 medical costs in the United States increased by only 2.5 percent compared with a 3.3 percent rise for consumer prices overall (Church, 1997). Not surprisingly, though, managed care strategies have had troubling consequences as well. …