From the Cardiology Department, Marshfield Clinic, Marshfield, Wis and
University of Wisconsin.
Correspondence to W. Bruce Fye, MD, MA, Medical Director, Marshfield Heart Care, Marshfield Clinic, 1000 N Oak Ave, Marshfield, WI 54449. E-mail fyew{at}mfldclin.edu
Physicians and other
healthcare professionals must become more active advocates for patients
in this new era of for-profit managed care. We must, for example, add
our voices to those of organizations such as the AHA and the ACC that
speak out on behalf of persons with cardiovascular
disease and institutions that advance knowledge through education and
research.1 2
During the early 1990s, for-profit managed care swept
over the American landscape like a flood, washing away medical
traditions and disrupting doctor-patient relationships. By now, the
fast-moving currents of managed care have reached virtually every heart
specialist and every cardiac patient in the nation. The unique
doctor-patient relationship, built on a centuries-old foundation of
altruism and trust, has been undermined.3 Individual
patients seeking personalized care are sometimes pushed around like
pawns on a chessboard. Meanwhile, doctors sometimes confront hastily
constructed but effective barriers that disrupt or destroy
long-standing relationships with their patients and their peers.
Most readers of Circulation would agree that
American cardiology is a brilliant achievement based on
the integration of research advances, technological and pharmaceutical
innovations, and highly trained clinicians.4 Heart patients
are living longer and better lives as a result of this fertile union
and enhanced emphasis on risk factor reduction. Not everyone shares
this optimistic view, however, especially those managed care executives
whose main goal is to spend less on health care in order to reward
their investors and attract new business.
The most aggressive leaders of for-profit managed care often seem
unconcerned with the ideals and institutions that physicians and
patients used to take for granted.5 They discount the
unique mission and special needs of America's academic health centers,
the factories of new knowledge that are a crucial component of this
nation's remarkably productive biomedical research enterprise.
Health care, in this age of deprofessionalization, is portrayed
increasingly as a simple commodity: physicians are providers and
patients are consumers of services. Although this interpretation may
appeal to some economists and investors, it surely troubles most
patients, nurses, and doctors.6
Managed care tries to influence medical decision making as part
of a strategy to encourage standardization and cut costs. The industry
has promoted the concept of the "gatekeeper," an unflattering
euphemism for primary care physicians charged with controlling access
to specialists, tests, and treatments. Many health maintenance
organizations now expect their primary care doctors to follow referral
guidelines such as those drafted by Milliman & Robertson (M&R), a
Seattle-based actuarial firm that pioneered the development of
proprietary healthcare guidelines a decade ago. Managed care
organizations purchase M&R's ambulatory care guidelines in part
because they provide simple algorithms for helping to decide when a
patient should be referred to a specialist. The lack of references and
outcomes data in these guidelines does not appear to have slowed their
diffusion or adoption.
The AHA warned recently that many primary care physicians are now
being pressured to "accept responsibility for patient care that could
be substantially beyond their level of training, experience, and
expertise."7 M&R's ambulatory care guidelines encourage
primary care physicians who feel comfortable doing so to treat patients
with angina pectoris themselves and to consult a cardiologist only if
symptoms persist "despite maximal medical therapy with maximally
tolerated doses of nitrates, beta-blockers and calcium channel
blockers."8 Given the risks associated with AMI,
consultation with a cardiologist before angina becomes intractable
would seem to be desirable.9
One unanticipated benefit of restrictive referral guidelines is that
they stimulated outcomes research to assess more objectively the
effectiveness of consultations, diagnostic tests, and
therapeutic interventions. Cardiologists have fared well in most of the
studies that have compared the outcomes of cardiac patients cared for
by primary care physicians or heart specialists.10 But most
cardiologists want to collaborate with primary care physicians, not
compete with them.11
Managed care can take credit for encouraging some positive
changes in healthcare delivery, such as the promotion of preventive
medicine and the accelerated development of case management tools that
help medical professionals deliver care in a more consistent
and efficient manner. To be sure, the medical community was developing
strategies to enhance efficiency and effectiveness before the managed
care revolution.
The dramatic reduction in the length of hospitalization for AMI during
the past half century is a compelling example of the success that
medical professionals have had in conserving healthcare resources while
preserving the quality of patient care. Topol and his
colleagues12 reported in 1988 that a brief 3-day stay was
safe in carefully selected patients with uncomplicated infarctions.
Managed care quickly adopted the 3-day target for some AMI
patients13 despite a warning from these authors that
further prospective studies were needed before their protocol could be
recommended for clinical use.
There is much to commend thoughtful and deliberate efforts to determine
the optimal length of hospitalization and the ideal location of care.
Most patients are willing to adapt to new strategies such as outpatient
angiography and shorter stays after AMI or angioplasty because they
trust the doctors and nurses who care for them. They need to know,
however, that the care maps they are expected to follow do not
recommend risky shortcuts.
Managed care is an impatient industry, especially when Wall Street is
involved. Healthcare professionals must be sure that aggressive
strategies to cut costs and enhance short-term profits do not harm
patients. We face special challenges when new policies are implemented
abruptly. For example, a managed care company in Wisconsin gave
hospitals less than 2 months' notice in 1994 that they would routinely
authorize just 5 days of hospitalization for patients undergoing CABG
despite the fact that fewer than 9% of CABG patients in the state were
achieving this target at the time.14
Continuing to challenge traditions and champion efficiency, the latest
M&R guidelines recommend even shorter hospitalizations for cardiac
patients whose courses are uncomplicated: 3 days for CABG and 1 day for
unstable angina, for example.15 Initially, M&R
presented their aggressive length-of-stay targets as "best
practice," a catchy but misleading phrase that had little to do with
high-quality outcomes. It referred instead to the most efficient
practices: those that used the fewest resources.
No matter how such cost-saving strategies are rationalized, managed
care plans are acting irresponsibly if they implement them abruptly,
without giving hospitals and healthcare professionals time to adapt. It
is like putting patients and their caregivers into an unfamiliar car
and urging them to drive too fast for conditions. Little wonder that
several thoughtful observers, including the editor of The New
England Journal of Medicine, have warned repeatedly that the
rapid shift to managed care as the way to contain costs has seriously
threatened the quality of health care in this
country.16
How did all this happen? Who was looking out for the patients
while for-profit managed care crashed like a tidal wave across the
medical landscape? Although a few individuals and organizations such as
the AHA and the ACC sounded alarms, it took a long time for most
doctors, patients, and legislators to hear them. Physicians, busy
caring for individual patients, and medical scientists, busy working in
their laboratories, were slow to articulate their concerns about this
dramatic departure in the organization of healthcare delivery.
The most vocal champions of managed care dismissed many of the
complaints and constructive criticisms. They stereotyped those who
challenged the principles and practices of managed care as
self-interested apologists for traditional fee-for-service medicine, a
system they characterized as anachronistic and fatally flawed. For
several years, the voices of patients were muted as well. But the
pendulum of public opinion is swinging back in favor of patients and
their physicians.17 The flurry of bills and laws dealing
with managed care proves that our patients' concerns are now
resonating on Capitol Hill and in state houses across the
land.18
Managed care is here to stay. It is a paradigm shift that has
forever changed healthcare delivery throughout this nation, from the
smallest towns to the largest academic health centers. Growing consumer
pressure and new laws promise to reduce the opportunities and
incentives for the most ambitious agents of for-profit managed care to
bully patients, doctors, nurses, and hospital administrators. Today,
healthcare professionals, concerned citizens, and politicians (all of
whom are potential patients) are helping to shape managed care into
something that places less emphasis on corporate profits and more
emphasis on patient choice and quality care.19
Recently, the American Association of Health Plans, managed care's
trade organization, launched a new program and media campaign called
"Putting Patients First." Managed care has a long way to go,
however, to achieve that worthy objective.20 Meanwhile, as
healthcare professionals, we share responsibility for injecting some
Hippocratic principles into the hyperbole of managed care. As we
advocate for our patients, we need to help this adolescent industry
mature into a socially responsible partner in healthcare delivery.
Selected Abbreviations and Acronyms
Footnotes
The opinions expressed in this editorial are not necessarily those of the editors or of the American Heart Association.
References
1.
Gamliel S, Politzer RM, Rivo ML, Mullan F.
Managed care on the march: will physicians meet the challenge?
Health Aff (Millwood). 1995;14:131–142.[Abstract]
2.
Katz AM. Health care reform: a threat to research and
education in the academic health center. Circulation. 1994;90:1572–1573.
3.
Mechanic D, Schlesinger M. The impact of managed care
on patients' trust in medical care and their physicians.
JAMA. 1996;275:1693–1697.
4.
Fye WB. American Cardiology: The
History of a Specialty and Its College. Baltimore, Md: Johns
Hopkins University Press; 1996.
5.
Mechanic RE, Dobson A. The impact of managed
care on clinical research: a preliminary investigation. Health
Aff (Millwood).. 1996;15:72–89.[Abstract]
6.
Relman AS. Medical care is more than commerce.
Wall Street Journal. November 7, 1997:A19.
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American Heart Association, Office of Public Advocacy.
Talking Points on Cardiovascular Care in a
Managed Care Setting. Washington, DC: American Heart Association;
September 1997.
8.
Healthcare Management Guidelines: Ambulatory
Care Guidelines. Seattle, Wash: Milliman, Robertson, Inc; 1996.
9.
Borowsky SJ, Kravitz RL, Laouri M, Leake B, Partridge
J, Kaushik V, Haywood LJ, Brook RH. Effect of physician specialty on
use of necessary coronary angiography. J Am Coll
Cardiol. 1995;26:1484–1491.[Abstract]
10.
Nash IS, Nash DB, Fuster V. Do cardiologists do it
better? J Am Coll Cardiol. 1997;29:475–478.[Abstract]
11.
Fye WB, Goldschlager NF, Messer JV, Rubenstein SA.
Referral guidelines and the collaborative care of patients with
cardiovascular disease. J Am Coll
Cardiol. 1997;29:1162–1170.[Medline]
[Order article via Infotrieve]
12.
Topol EJ, Burek K, O'Neill WW, Kewman DG, Kander NH,
Shea MJ. A randomized controlled trial of hospital discharge three days
after myocardial infarction in the era of reperfusion. N
Engl J Med. 1988;318:1083–1088.[Abstract]
13.
Healthcare Management Guidelines: Optimal
Recovery Guidelines. Seattle, Wash: Milliman, Robertson, Inc;
1995.
14.
Brown J. ACC chapters are increasing private sector
activities. Cardiology. 1995;24:10.
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Healthcare Management Guidelines: Optimal
Recovery Guidelines. Seattle, Wash: Milliman, Robertson, Inc;
1996.
16.
Kassirer JP. Dr. Kassirer replies. N Engl
J Med. 1997;337:1086.
17.
Bodenheimer T. The HMO backlash: righteous or
reactionary? N Engl J Med. 1996;335:1601–1604.
18.
Miller TE. Managed care regulation: in the laboratory
of the states. JAMA.. 1997;278:1102–1109.
19.
Hamburg RS, Ballin SD. Recent polls and reports show
strong support for maintenance of quality in managed care.
Circulation. 1997;95:765.
20.
Kassirer JP. Managing managed care's tarnished image.
N Engl J Med. 1997;337:338–339.
© 1998 American Heart Association, Inc.
Editorials
Managed Care and Patients With Cardiovascular Disease
Key Words: Editorials • managed care programs • patients
ACC
=
American College of Cardiology
AHA
=
American Heart Association
AMI
=
acute myocardial infarction
CABG
=
coronary artery bypass surgery
M&R
=
Milliman & Robertson, Inc
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