Managed Care
and Honesty
by
Joseph N. Michelotti, M.D., M.A., F.A.C.S.

Physicians rationalize their willing participation in an inherently corrupt system.

If the great orator Demosthenes were alive today, his legendary search for an honest man would end at the office of Dr. Michael Greenberg in Elk Grove Village, Illinois. Dr. Greenberg's personal account (AMNews My opinion, March 11, 1996) describing how physicians rationalize their willing participation in an inherently corrupt managed care system is startlingly honest. In matters of health our patients are dependent and vulnerable, and retain us for our professed knowledge and skill. The distribution of power in the doctor patient relationship is so unequal that it creates a number of moral obligations for physicians, not the least of which is that medical advice must be in the patient's best interest. When a managed care contract conflicts with the unwritten but legally recognized doctor-patient contract, it is easier to covertly violate the latter than the former. This practice is so abhorrent that it requires us to deceive ourselves by arrogantly proclaiming our capacity to put aside self interest “for the good of the patient.” Other professionals such as attorneys, and even politicians, are honest enough to recuse themselves from situations where a conflict of interest is recognized.

Altruism is rare indeed, and it is unrealistic to expect anyone, including physicians, to function contrary to their own self interest. That is why the millennia old health care system of “fee for service” evolved to reward the physician for honest and compassionate health counsel, and the highest quality medical care that is practically available, as judged by the patients receiving it (and paying for it). Over utilization is easily detected by a patient who is responsible for the bills, but under managed care it is much more difficult for a non-physician patient to detect under utilization . . . what could or should be done. Today's astronomical health care bills, often blamed on fee for service, are the result of a third party payment system which has, over the years, dismantled fee for service. Fee for service means the recipient of the service pays the fee, and that is the only way it can be expected to work. Under true fee for service, success depends on providing good service at a reasonable fee. It is ironic that America is abandoning fee for service in search of those objectives.

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