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There is nothing more bracing for the mind than a critical exchange of views. I, therefore, read with keen interest the letters in the September 5 issue that responded to the story about my annual meeting paper on ethics and managed care in the July 4 issue.
Richard Shadoan, M.D., in the longest and most critical of these letters, provided a thoughtful rebuttal to my views. He emphasized that rather than winning or losing the managed care battle, "psychiatry is changing. . .and the ‘winners’ will be our patients." Although I agree that psychiatry is changing, I see evidence everywhere that health care in America is in a lean and mean profit-driven race to the bottom in which all patients, and particularly psychiatric patients, will suffer.
Dr. Shadoan is correct that a wave of state legislation against managed-care scrimping looms on the horizon. Recent polls also suggest that the public has begun to distrust managed care, and this may encourage state legislators to do something. What Dr. Shadoan may not realize, however, is that most major corporate managed care plans are protected against those state laws by ERISA. Although there are legal ambiguities, it is clear that until ERISA is amended, all these new state laws will not change managed care’s lean and mean practices. Most physicians do not seem to understand that ERISA preempts state law, and because of this, real change must come from Washington.
Dr. Shadoan misunderstood the nature of the information problem I was describing. Kenneth Arrow, the Nobel Prize-–winning economist, long ago wrote about the incorrigible information problem in the health care market. His thesis was that efficient markets can develop only where purchasers have good information. Ordinary patients cannot obtain enough good or useful information about the nature of their illnesses or the quality of their doctors, hospitals, and health plans. Informed consent, second opinions, etc., are small first steps in solving the information problem. Arrow concluded that because of this information problem, doctors should have fiduciary obligations to patients. Managed care undercuts our fiduciary obligation while it further complicates the information problem.
I do not know if other psychiatrists share my experience, but with the advent of managed care, I find that in making referrals, it is much harder to get good information about the quality of medical and surgical specialists and the care they provide. Furthermore, it is now much more difficult to refer patients to physicians of high quality because of network limitations. If there is a world of more choice and better information for patients under managed care, I have not found it.
Finally, Dr. Shadoan argues that our traditional fiduciary obligation is not in conflict with the ethics of covered lives. Indeed, he suggests that the ethics cannot be problematic since they come from community psychiatry. Unlike Dr. Shadoan, I think the ethics of covered lives is highly problematic because it comes from community psychiatry. First, the community mental health movement was something less than a success, and our patients were the losers. More important, however, Dr. Shadoan fails to recognize the difference between the ethics of covered lives in the public context of community-based institutions as opposed to the private context of for-profit health plans that trade on Wall Street. When a psychiatrist is a public servant or official, he or she should worry about covered lives, the common good, and distributive justice. But when a psychiatrist moves to the for-profit sector, the ethics of covered lives serves not the common good but shareholders’ profits.
Yes, Dr. Shadoan, I believe a "very dangerous" shift in perspective has occurred because the ethics of community psychiatry has been wrenched out of its proper context and become a rationalization for a lean and mean health care system that rewards shareholders, not patients. I have nothing but admiration for psychiatrists who try valiantly to work with limited public funding to distribute mental health care more equitably and effectively to the community. However, it is sad to see these good soldiers of the community mental health movement become the mercenaries of managed care. Their once-valiant endeavors become unworthy when the budget is set by a corporation seeking to enrich its Wall Street value. Corporations, like physicians, have legally binding fiduciary obligations, but they are not to the patients in their plan but to their shareholders. "Covered lives" in the private sector is not about the common good or about public health; it is about profitability and the bottom line.