The great botched experiment in health reform casting a shadow over today's debate is not the failed Clinton initiative, but the subsequent temporary embrace of managed care. Today's environment is very different, because the old idea of promoting evidence-based medicine is now being linked by policy makers to the creation and reliance upon new government research which will involve culling through computerized patient records.
This means that the stage has now been set to argue, once again, the issues that were raised so ineptly during the managed care episode. The idea of managed care - finding the best way to deal with a problem and making that the default approach - is a pillar of reforms now under consideration. That's why the same arguments that quickly forced managed care into retreat are being used again today and why it is important to come up with a compelling response - something a bit more compelling than "this is not your father's managed care."
There were some massive failures of communication, starting with the basic idea, which involved the use of evidence-based medicine to maximize the odds that doctors would use the right therapy at the right price. It is important to acknowledge that the goal was to deliver good care for most patients most of the time rather than delivering the best possible care to every patient every time, an improbable goal not worthy of serious consideration outside of Lake Woebegone.
When the issue arose in the 90s, scathing media reports fed by unhappy providers convinced employers to back away from that approach and move instead to plans where workers were forced to pay more for a broader array of choices - despite data showing that about half of consumers prefer the idea of paying less for a plan that offers fewer choices.
But the idea is a compelling one that we keep coming back to. What happened a decade ago was an echo of Richard Nixon's efforts a quarter century before to encourage the growth of health maintenance organizations. In each case, the idea is promoting evidence-based medicine.
Think of it as a system not unlike synchronizing traffic lights to maximize traffic flow. Done right, it allows all to move a bit faster. But I could go faster if all other traffic stopped to let me by. Or think of an emergency room that does triage well, treating the sickest first. My care would be better if they simply bumped me to the head of the queue when I arrived irrespective of my complaint.
If things work right with managed care, you maximize the odds of getting care that is at least adequate, while simultaneously lowering the odds that you'll get care that is either extraordinarily good or bad. In medicine, that means simply waiting a bit when dealing with problems that often solved themselves, using simple tests (like x-rays) that could adequately provide needed information rather than complex, expensive ones (like MRIs or CAT scans), trying drugs before resorting to surgery when both were possibilities and using a generic drug with a track record before switching to an expensive new option where side effects remained a mystery.
All this was based on a theory - called science by some -- that those with large amounts of data knew what worked best and should share their findings with those delivering the care, which is a hard theory to argue with. Unfortunately, those who knew the most tended to be affiliated with insurance companies, who are at an inherent disadvantage when dealing with the doctors we have a personal relationship with and rely on.
These managed care firms were perceived, not entirely incorrectly, as being solely interested in saving a buck by saying no - which is a profitable habit familiar to those who deal with any type of insurance. Doctors were understandably impatient with insurers who not only imposed costly new administrative requirements before approving care, but sometimes responded by terming the care they recommended as inappropriate, a decision that caused the doctors psychological and financial discomfort.
Patients forced to choose between face-to-face English-language conversations with their respected doctor and bureaucratic insurance firm responses delivered from disembodied voices at call centers had a tendency to favor the former and their resulting frustration ultimately resulted in a retreat from managed care, which is recalled today only via some sour jokes about HMOs. What is less realized or remembered is that managed care worked. Despite rhetoric about their power, insurance companies proved to be ineffective communicators at best, never convincing people that their goal (at least their stated goal at least part of the time) was to get the best possible care from the best providers.
Despite complaints, there's no evidence that patients stayed sick longer or died more often during this period and there is evidence that medical costs moderated. When managed care disappeared, they again grew explosively. Often employers insulated themselves by having workers pay the extra costs involved. Basically, they said workers who wanted extra choices would have to pay extra for it.
Another painful residue of this experiment were a series of "any willing provider" laws enacted by a number of states that required insurers to include any credentialed doctor who was willing to live by their rules, thereby sabotaging insurer efforts to push patients toward the most efficient providers.
Whether promoters of change have learned enough to make a better case this time is a key question.
Reviews: See review of article at Health Beat .