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I am writing in response to the article "Managed Care Now 'Firmly in Control' But Its Final Shape Remains in Question" in the March 6 issue. The article states that managed care came into existence because of the three problems of cost, quality, and access, but it offers no evidence that managed care has solved or even addressed any of these problems. In fact, the reason that managed care is in control is because it has provided bigger profits to health care corporate management and stockholders than has any other system of health care financing. It has achieved these profits by shifting costs, limiting care, and restricting access.
First let us look at costs. Clearly, managed care has decreased the rise in premiums paid by corporate buyers of insurance, but much of these savings come at the expense of others (American Journal of Psychiatry, June 1994, p. 151). The clearest example of this phenomenon is the Florida Medicare study, showing that patients who need services find their way out of their managed care option into the fee-for--service sector (New England Journal of Medicine, July 17, 1997, p. 169-175). Additionally we see the constantly growing number of uninsured Americans, most recently reported to be more than 42 million. These people are still costing the nation a great deal-they just don't show up on the managed care ledger.
As for quality, the article makes an evasive statement about the jury still being out on "focused, time-limited, goal--specific treatment. . ." favored by managed care. In fact, no study to date has found that managed care has been able to provide psychiatric services as effectively as fee for service. Every comparative study to date has shown patients in managed care do less well regardless of treatment used (Archives of General Psychiatry, July 1993). The jury seems to be in, and managed care has failed.
Finally there is the question of access. Again the increasing number of uninsured speaks to the inability of our current system to provide access. The Governor's Commission on Managed Care in California is proposing legislation to ensure that people are granted access to specialty care (Action Report, Medical Board of California, April 1998, p. 1-4). The need for this legislation speaks to how poorly managed care has handled specialty care access, even for those people it allows into its system.
The fact that managed care is "in control" despite having failed to solve any of the problems that are credited with bringing it into existence shows that these are not the real focus of attention. What managed care has succeeded in doing is milking more profits out of health care premium dollars than has any other system. Evidence of the truth of this statement comes from the unprecedented number of not-for-profit health plans that have converted to for-profit status in the past five years. If quality service delivery, and not profit, were the reason for the managed care revolution, then there would be no reason for these conversions. These profits have come at great cost to patients, but patients are no longer the focus of American medicine; Wall Street is.
Michael V. DeLollis, M.D.
Fresno, Calif.