Response to Clinical Issues Raised on Managed Care

Managed care, in its manifold forms, has resulted from complex economic, social, and political forces. Early health maintenance organizations (HMOs) were developed, in fact, as cooperative ventures between unions and management to ensure access to medical care for all employees of large companies. J,~ More recently, HMOs and other managed care entities have operated on a for-profit basis. The recent emphasis on selling and marketing a medical product is evident throughout all forms of health care delivery. Individual practitioners and private hospitals are marketing, advertising, and packaging their services in forms that would have been deemed unethical (and certainly in poor taste) fifty years ago. Discussions of managed care have tended to focus on the evils of the "profit motive" and therefore may be asking the wrong questions, since all forms of medical practice are bound by economic forces. The right questions are those which are posed regarding any new form of practice: what is the quality of care delivered?; how does it compare to more traditional forms of practice?; what are the ethical and legal dilemmas raised?; and how does access to care compare to other systems? Dr. Docherty's paper 3 is concerned with the areas of patient-therapist relationship, treatmentmatching and planning, and the ability of clinicians within managed systems to provide quality care. Managed systems certainly pose challenges for the individual patient-clinician relationship. One challenge comes from the underlying principle of a "public health" model of care. Any prepaid care system contracts to provide care, within acertain subscriber agreement, to a l~.pulation ofenroUed members. In that sense, an HMO operates more like a public clinic or community mental health center. The individual clinician must also be aware of a panel or group of patients rather than just the patient in his/ her office. While these concerns may, as Dr. Docherty states, "bring jeopardy to the integrity of the clinician-patient relationship, ''3 it is important to consider that the only relationship that can exist in feefor-service practice is one in which the patient can afford the fee and the clinician has the time. Many patients thus receive no care at all. Many recent studies 4,-5 have shown that in managed systems, more patients seek psychiatric treatment than under traditional forms of care. Quality assurance and utilization management can certainly become invasions of privacy and a waste of valuable resources. However, the examination of the decision-making and treatment-planning process in psychiatry can also add valuable data to a field which has been floundering in providing answers to such questions as "which treatment works best for whom?" Dr. Munich's paper;' describes a process in which a hospital staff, challenged with the demands of external utilization review, developed a process which not only helped them to meet these demands efficiently, but promises to improve their ability to focus and structure hospital care, and provide them with data to improve their own care systems. The clinician working within a managed system does deal with an inherent conflict of interest. He/ she is working for a patient, for an HMO, for the patient's employer who pays the premium, and perhaps