Once upon a time there was a health care system in a not too far away land where patients paid doctors directly for their services (just like the clients of veterinarians do today) or purchased health insurance policies sold by companies who based their cost of doing business on their expenditures plus a reasonable added profit.  It also used to be that Medicare, which was created to pay hospital bills, actually paid hospital bills rather than dictate health care and levels of reimbursement.  The private insurers, in the past, did little in the way of advertising, lobbying, or contributing to political causes because they didn't have to. Their clients were typically in charge of their destiny and free to choose their doctor, hospital, and to be in charge of their healthcare decision making. There was a high level of satisfaction with this arrangement.  Until the cost of health care began to rise!

Even though much of the increase in health care costs has reflected better technology and better treatment (as evidenced by our increasing longevity and quality of life) those in authority advised us that the percentage of the Gross National Product (GNP) relating to health care was becoming disturbingly high and that major changes in the system were necessary. When these concerns were first addressed health care represented less than 10% of the GNP in the United States.  Health care now represents 15% of GNP.  This leads one to consider the following question: if health care were, for example, 20% of GNP and if the public received appropriate value for this expenditure would there really be a problem? 

Chris Farrell has stated that after weighing the costs of health care and comparing these to the returns from technology in increasing productive life span and quality of life this may very well be society's best buy (Farrell C: Health care spending is a good thing, Star Tribune, August 8, 2003).  Peter Huber (Medicine Gets Cheaper, Forbes, March 1, 2004) advances the point of view that the real cost of health care "has been declining steadily for the last 50 years" because of the dramatic decreases in the economic cost of illness over the past half-century.

Given these facts wouldn't it be better still, if it were possible to decrease health care costs to less than 10% of GNP and continue the enhancement of health care quality as well as continued improvement in the productive longevity of the  individual? 

As a Minnesota-based online publication it is an act of contrition for us to bare our souls and confess our collective guilt in having been accomplices to much of what has been perverse in health care in the United States during the last part of the 20th century.  Understanding how managed care and health maintenance organizations (HMOs) came to be is an important part of being able to follow this still unfolding remarkable chronicle.  The direction in which this saga is heading is partially exemplified by the following survey:  

Yes, the state Minnesota has been the "mother" of the HMO movement.  Can one believe that that the placid shores of "Lake Woebegone" and the home of  "Minnesota Nice" have given birth to this oft despised industry?  Sadly, the specific onus for this aberration rests squarely on the shoulders of pediatric neurologist Paul Ellwood and associates.   It is interesting to hypothesize that if HMOs had been initially introduced into a venue other than Minnesota they probably would not have survived past the starting gate.

The heartbreaking part of all this is that if  HMOs had really chosen to focus on health maintenance and prevention, as Dr. Ellwood had intended in the first place, they would probably have been able to achieve continuing financial success by providing needed health care benefits while also gaining their client's appreciation for such efforts which, unfortunately, has not been the case.  Once HMOs eliminated the "fat" in the health care system their continued squeeze has served only to starve it.  It seems that the characteristic HMO  modus operendi has been to raise premiums and reduce services while also engendering huge profits.  Recently it has become a common practice for HMOs to balance their avarice by  instituting "health programs" and giving discounts for things such as health club attendance. 

Ross Perot's great "sucking sound" example should have been directed to managed heath care where executive and shareholder profits have replaced patient consideration.  One Minnesota HMO has given a discount to clients who would use a health club 8 times a month.  Unfortunately , this opportunity was so well subscribed to that the reimbursement is now only provided when the health club is attended 12 times a month.  Need more evidence of where their true hearts are? Health care is now over a $400 billion industry in the United States.  There is no evidence to suggest that a HMO or any socialized system is a better approach toward making "sick people better."

Leland Kaiser PhD, a health care consultant and futurist has observed that, in the United States, "We have a disease system, not a health system." He pointed out, for many years,  that while we are excellent in treating disease we are not very good at creating health or preventing disease.  Well, we are still not very good at creating health and managed care hasn't done much to achieve what Dr. Paul Ellwood really had in mind at the beginning of all of this.
 

Following the introduction of the HMO prototype there has been a literal wagon train of  managed care programs and managed care products being created in the United States.  Managed care is now a huge, and powerful, industry.  This big business enterprise has promised America better care, more comprehensive services, quality of care monitoring, and lower premiums.  Employers initially saw this as nothing short of wondrous and literally fell over themselves jumping on the HMO bandwagon.  They are now having serious second thoughts on this issue.

Part of the initial success of the managed care industry reflected its unusual power and privilege.  The power part has reflected sometimes outrageous profits producing a attitude best described as the "Golden Rule of Health Care.  This translates out to: "those who have the gold make the rules."  Also adding to the financial largesse of managed care has been the boon of not having to be legally responsible for reprehensible behavior due to ERISA-provided immunity. 

By excusing managed care from the responsibilities required of other organizations (excepting government and military) it is clear that the disenfranchised patient still has little recourse to effectively right wrongs.  The last thing a sick patient needs is more stress and adversity.  Managed care has done more than its share in providing this.  A physician, and former insurance claims examiner, Linda Peeno, M.D. (knowledgeable as an ex-insider in the managed care industry), has provided court testimony that while HMOs promise coverage based on medical need they actually use a number of strategies, including the routine denial of a certain percentage of claims, to place cost-savings as their most important goal (Former Insider Helps in Suits Against HMOs, Wall Street Journal, Nov. 26, 1999 by Philip Connors). 

Imagine discovering that when the "chips are really down", and you need prompt medical care, that a cost-cutting exclusion was part of, or was written into, your health care contract and that your future survival may be dependent on whether or not a clerk has had a good day, or is willing to even answer a phone.

Are there alternatives? Of course there are.  Create independent Health Savings Accounts (HSA's) for patients.   Medical Savings Accounts (MSAs) only represent one such example of sane and attractive HSA's. The MSA model represented the first productive change from managed care where consumers are provided with precious little real information about the cost of their health care services and are provided with few real incentives to "stay healthy."  

There is no question but that the focus on HSA's has received a significant boost with the support of President George W. Bush through the December, 2003 Medicare overhaul legislation.  About 20 financial institutions are now offering new programs to both individuals and employers (Story L: Health Savings Accounts Gain Momentum, WSJ, Sept. 9, 2004) and as of 2007 there were 3,000,000 enrollees in the U.S.

Another interesting "slant" on health coverage is the Federal Employees Health Benefits Program (FEHB) for federal employees which transforms health care coverage into a buyer's market in which the insurers compete for clients.  Because federal workers pay a portion of the premium there is some incentive for them to remain healthy but the destiny of these workers still is dependent upon the mercy of their insurers.  A close look at the FEHB initiates concerns regarding the wisdom of our government's creation of a two-tier health care system reminiscent of the Soviet berioska shops.  Do we really need to impose a failed "classist" impediment upon American where "all men are created equal"? 

As you read this online you now have, at your fingertips, more potential health care information than anyone has ever had in the history of the world.  If you don't believe this ask www.google.com.  Wouldn't you rather use this information (and your own good judgment) to make your own decisions and use your personal buying power to shop for the best care available from the most experienced practitioners? 

Why not contribute to making our  health care system a continually better rather then worse by encouraging competition?  Just try to get managed care providers to provide you with reasonable answers to your inquiries (assuming you have the patience and fortitude to wait on the phone long enough to actually talk to a human being).  Just try to get a rational explanation as to why your treatment is being denied as "unproven" when few things in all of medicine are "proven."

The dark side of managed care does not just pertain to its dismal record of denying treatment, decreasing service, and increasing cost to their customers.  It also has to do with a continuum of disrespectful and unprofessional behavior directed to patients in a multiplicity of ways.  Managed care is now under siege and is digging in to combat this by using their, not inconsiderable, financial resources to influence opinion by purchasing prime-time advertising and establishing ready response units to counter attacks on managed care throughout the country.  They are also just beginning to "discover " some things that everyone else has known all along. Their lobbyists have at their disposal the results of surveys indicating a high public satisfaction with managed care.  Independent surveys, however, show that public opinion varies considerably depending on the actual phrasing of the questions being asked and the nature of the audience being queried.
 

 
Can  managed care really be as bad as it seems?  Well, let's face it, nothing is all bad.  It's just that one can't build a sound house on a structurally flawed basement. With the advent of the new enterprise "cyberpharmacology" on the Internet the phenomenon of physicians prescribing drugs for individuals they have never seen has now been introduced. On June 24, 1999, Nancy Dickey, President of the American Medical Association was quoted as stating that when the patient and the doctor are strangers, prescribing a drug is "unethical." Carmen Catizone, Executive Director of the National Association of Boards of Pharmacy, has been quoted as stating those filling prescriptions "without a legitimate patient-physician relationship, we consider it illegal." (New York Times, June 27, 1999). Well then, where were these good people with their high-sounding judgments when managed care reviewers, also total strangers to the patient, were denying prescribed medical care and participating in other abuses for which they were given a "free ticket" in regards to both financial and societal responsibility?  What are the ethics of managed care?  What, if any, will be the consequences of this unethical behavior?