EMBARGOED FOR RELEASE: 3 p.m. (CT) Tuesday, March 25, 1997
Media Advisory:
To contact John H. McArthur, D.B.A., call Loretto Crane at 617/495-6155.
To contact Francis D. Moore, M.D., call Esther Carver at 617/732-5008.
To contact Linda Emanuel, M.D., Ph.D., call Mark Wolfe at 312/464-5970.
New Health Care Model Needed to Balance Economics vs Professionalism in Medicine Conflict between economics and medical needs in current health system creates dilemmas
The conflict between professionalism and profit in health care today needs to be addressed by creating a new national agency, according to an article in this week's issue of The Journal of the American Medical Association (JAMA).
John H. McArthur, D.B.A., of the Harvard Business School, and Francis D. Moore, M.D., Brigham and Women's Hospital, Harvard Medical School, Boston, Mass., write on the problems created by competition between commerce and professionalism in medical care and propose health care models to lessen these problems.
They write: "The current trend toward the invasion of commerce into medical care, an arena formerly under the exclusive purview of physicians, is seen by the authors as an epic clash of culture between commercial and professional traditions in the U.S. ... It is our purpose here to explore threats to the quality and scope of medical care that arise when the tradition of medical professionalism is overtaken by the commercialism ethic and by corporations seeking profit for investors from the clinical care of the sick."
The authors cite 12 potential hazards of the commercialization of medicine. They include:
-- Diversion of funds: When a portion of funds for the care of the sick are diverted for corporate objectives (such as dividends, advertising, executive salaries), the resources available for health care are thereby reduced.
-- Pricing: Unless regulated, the charity threshold (the income level below which family costs for medical care must be borne by church, charity, or government) will inevitably rise as health plans and other insured providers increase prices and/or decrease services to ensure profitability.
-- Risk Avoidance: Exclusion of individuals and families from coverage because of prior disease, genetic constitution, predisposition, or high cost denies care to those most in need and is not a characteristic of national health insurance plans in other industrialized countries.
-- Downgrading of Personnel: Highly qualified but expensive personnel will be threatened by discharge in favor of others with less experience and fewer credentials but lower income expectations.
-- Managed Care: To many, the term "managed care" implies the need for concern about the welfare of the patient because they suspect that care is being managed to minimize expense and perhaps even maximize income for the employer, provider, and/or insurer, while masquerading as a benefit for the patient. The term is increasingly interpreted as meaning "managed costs" rather than "managed care."
-- Monopoly: Loss of Free Choice: Free enterprise commerce fosters competition and encourages consumer choice among alternatives, but these choices cannot operate in rural areas, smaller communities, or inner-city areas where the population and financial resources are insufficient to attract more than a single prepaid health plan or HMO. Freedom of choice, long considered an ideal by-product of free competition, is compromised.
The authors write: "Whether by voluntary self-regulation or by the passage of regional or national legislation, minimum standards will inevitably be required to abate some of the hazards to society and abuses of patient care arising from commercial pressures on professional behavior. These standards address the potential hazards we mentioned in the foregoing. Acceptable profit levels will require definition, as well as allowable diversion of money to dividends, executive bonuses, promotional expenses, advertising, etc."
The Need for a New National Agency
They write: "Standards for and surveillance of medical commerce and prepaid plans urgently require the establishment of an entirely new sort of agency, ideally in the private sector, free of control by individual and institutional providers, government, insurance corporations and underwriters, consumer advocates, professional societies, or hospital associations. Initially, the launching of such an agency might be supported by grants from a consortium of national charitable foundations that have been committed to health policy analysis."
They also write: "While it is beyond the scope of this brief article to elaborate the operational details of such an agency, certain guidelines recommend themselves. The National Council on Medical Care (NCMC) might initially embrace representation from a few authoritative constituencies [American Medical Association (AMA), the Health Insurance Association of America, and the Institution of Medicine] who would form its executive committee." Voluntary Standards and Self-regulation: The Level Playing Field The authors write: "There is a fine line of distinction between establishing agreed-upon pricing and service guidelines in the public interest on the one hand and unacceptable monopolistic collusion on the other. Encouragement for, cooperation with, and surveillance of such associations within the health care industry would be among the continuing objectives of the NCMC. It would remain of ongoing importance to avoid an adversarial relationship (arising from the approval function of the of the NCMC) between the NCMC and those corporations or insurers providing clinical care."
They write: "If, as a result of the entry of commerce into American medical care, national standards (as mentioned above) become a reality--with appropriate agencies for surveillance, reporting, and local assessment of the adequacy of health practices--this will be a major benefit from the commercialization of American medical care. While access to capital investment will be a benefit from the entry of commerce into medical care, some caution and some years of experience will be necessary before realizing this benefit."
Editorial: Market Medicine Needs to be Accountable In an accompanying editorial in this week's JAMA, Linda Emanuel, M.D., Ph.D., from the Ethics Institute, AMA, Chicago, Ill., writes that new structures for maintaining professional standards may not be necessary. "...it is more to the point to redirect existing structures [AMA, the Joint Commission on Accreditation of Healthcare Organizations, the National Committee for Quality Assurance with its Healthcare Employer Data Information Set] to suit the specific standard-setting needs of current commercialism. Indeed, appropriate new awareness of and commitment to using a refocused professional map have emerged in the last few years. New programs and initiatives have emerged in many existing organizations for the purposes of maintaining physician and service organization standards."
Concerning the issue of ethics, "the Ethics Institute of the AMA plans to create this kind of accountability on ethics standards. It will establish a database on health delivery organizations, based primarily but not exclusively on physician survey assessments, to evaluate how well organizations permit the upholding of and nurturing of previously identified professional and ethical standards of practice ... This program essentially uses market tools, leveraging the powerful effect of reputation for ethical or unethical conduct, to insist on professional standards no matter how aggressively commercial the business setting."
Dr. Emanuel continues: "... unless investors in medical business can be held accountable for promoting medical professional standards, managers will always have an imbalanced motive to give priority to investment returns. Novel approaches to making investors accountable for permitting professional standards are called for. Report cards are not applicable to investors, but states could be periodically evaluated by the profession on relevant regulations."
Dr. Emanuel concludes: "Professionalism requires restraints on profit-seeking activities, both as a moral matter and as a pragmatic one. The marriage of medicine with business is not optional. It is, for better or for worse, necessary. It is only a question of how constructively or destructively the two coexist, and some moderation in profit motive is a precondition for a constructive long-term partnership with medicine."
# For more information: contact the AMA's Jim Michalski at 312/464-5785. email: [email protected] AMA web site: http://www.ama-assn.org
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