morefire

main | table | intro| 1 | 2 | 3| 4 | 5 | 6 | 7 | 8 | 9 | 10 | 11 | 12 | 13 | 14 | 15 | 16 | 17 | 18 | *

Notes

Chapter 1

1)This chapter has gained much from "Integrated Mental Health Services" edited by William R. Breakey, Oxford University Press, New York, 1996.

Chapter 2

(2)"The Rise and Fall of the State Hospital" by William R. Breakey, is a chapter in "Integrated Mental Health Services1. In this chapter, Dr. Breakey comments that progress in the care of the mentally ill has been cyclical. Dr. Breakey outlines the events from colonial times that preceded current situations.

A vivid portrayal of the conditions prevailing in mental health facilities by mid-20th century is contained in "The Turning Point" by Alex Sareyan, American Psychiatric Press, Washington, D.C., 1994. This book gives a description of the work of conscientious 1objectors during World War II. Their commitment led to important reforms in public mental health hospitals throughout the U.S., and laid a solid foundation for change in the care of the poor mentally ill in the country.

(3)Henry Ford's ideas about his "poor man's hospital", Henry J. Kaiser's plan to capitate his workers, and health care cooperatives are as those proposed by Shadid and others, are discussed in "Capitation, Integration, and Managed Care" (JAMA. 275: 947 &endash; 962, 1996.) Our intention in this chapter was to establish a contrast between the early efforts in community health care and the new managed care industry. As pointed out in the 1996 article, even the Kaiser experiment was intended to offer "physicians more autonomy than was allowed by the salaried model".

(4)JAMA (275, 957, 1996)

Chapter 3

(5)"The Doctors Mayo" by Helen Clapesattle (Pocketbooks, New York, 1968, is an extraordinary and readable account of the major changes that occurred during the period the Doctors Mayo practiced medicine.

We chose to stress the Doctors Mayo because they presided on a major transformation of medical practice in a relatively short time. A more formal explanation of events and change can be obtained in "The Growth of Medical Thought" by Lester S. King, (The University of Chicago Press, Chicago, 1963).

A major difference between physicians and the entrepreneurs that have come in with managed care is that the physicians have often put themselves and their lives on the line in order to help their patients. An extreme example is presented by Dr. Werner Forssmann, in his book "Experiments on Myself" (Saint Martin's Press, New York, 1974). Dr. Frossmann describes in the book how he as a 25-year-old interns in a small hospital in Germany, inserted a catheter into a vein in his left arm and directed it up into his heart. This experiment, done without anesthesia, and recorded by x-ray photography, opened the way to modern heart catheterization.

Chapter 4

(6)The partnership between cardiologist, Paul Dudley White, and psychiatrist Mandell Cohen, is well documented in the book "Doctor Heart &endash; The Life and Prescription for Living of Paul Dudley White, the World's Premier Cardiologist" by Paul Ogelesby, (Harvard University Press, 1986).

After his pioneering work on anxiety disorders, Dr. Cohen went on to mentor Eli Robins, who organized and led the team that created diagnostic categories today widely used as part of the DSM process.

Chapter 5

(7)"Health Insurance and Psychiatric Care: Utilization and Cost" by Louis S. Reed, Evelyn S. Myers, and Patricia L. Scheidemandel (American Psychiatric Association, Washington, D.C., 1972) has acquired historical significance because it gives an account of the costs of mental health care before the emergence of managed care. These costs were much lower then than the cost today under managed care. One can claim that the enormous decrease in services under managed care has only damaged quality without decreasing costs.

(8)Dr. Elwood's 1966 formulation is contained in his article Quantitative Measurement of Patient Care Quality Part II, a System for Identifying Meaningful Factors, Hospitals 40: 59-63, 1996.

(9)During the dominance of managed care, Dr. Paul M. Elwood, and Dr. Alain C. Enthoven became public figures who often gave opinions and wrote articles on managed care. In our view, the best presentations they made were the Shattuck lectures. Dr. Enthoven gave his lecture in 1978 (The New England Journal of Medicine 298: 1229 -1238, 1978). Dr. Elwood gave his lecture in 1988 (The New England Journal of Medicine 318: 1549 -1556, 1988). Though these lectures represented the core of their thinking, they probably do not reflect their thoughts as of today. More recent writings would indicate that both Dr. Elwood, and Dr. Enthoven are prepared to react to new realities. We take their stand on pre-tax medical savings accounts as a demonstration of the evolution.

(10)Dr. Elwood's comments on how his vision was derived are contained in an interview published in Medical Economics on May 13, 1996. The title is "How Doctors Can Regain Control of Health Care".

(11)The comments on pre-tax MSAs contained in "Responsible Choices:The Jackson Hole Group Plan for Health Reform" by Doctors Elwood and L. Tobin (Health Affairs Summer 1995: 24-39).

(12)The Shattuck lectures were considered by many as "classics". Not less "classic" was the article "The Monetarization of Medical Care" by Eli Ginzberg (The New England Journal of Medicine 310: 1162 &endash; 1165). The last paragraph of this article appears extremely timely today. "To secure its long-term financial foundation, American Medicine will require a combination of political leadership and professional cooperation that is not yet visible on the horizon. The great danger is that such cooperation will be delayed past the point at which intervention can be effective."

(13)Events in the 1990s have proven that positions presented by William B. Schwartz, M.D., in his paper "The Inevitable Failure of Current Cost Containment Strategies", (JAMA 257: 220 &endash; 224, 1987) were right on target. Dr. Schwartz position was a direct response to Dr. Enthoven's opinions. Dr. Enthoven had expected that costs would be controlled by eliminating care that was presumed to be of no medical value. Even accepting that there was unnecessary care at the beginning, which has not been proven, the decrease in services that have accompanied managed care has not reduced costs. If one considers increases from the time-managed care started, there has been an increase in costs of more than 700%.

Chapter 7

(14)Wendy K. Marinerer, J.D., M.P.H., wrote "State Regulation of Managed Care and the Employee Retirement Income Security Act", (The New England Journal of Medicine 335: 1986 &endash; 1990, 1996). The whole fourth paragraph of this chapter is a direct quotation from that article. Dr. Marinerer's opinion has been expressed in Congress many times "as long as States are charged with regulating private insurance, Congress should amend ERISA to permit them to regulate managed care, whether or not it is provided through an ERISA Plan".

(15)Dr. Welch's analysis was published under the title "Manage Care Litigation: The Foundation is Laid" the Psychiatric Times, August 1999 (pages 11 and 14).

In the fall of 1999, the Illinois Supreme Court ruled that patients can sue health maintenance organizations for malpractice, the claim that decisions on what treatment the companies will cover amount to medical care. In the decision, Chief Justice Michael Bilandic wrote "Where an HMO effectively controls the physician's exercise of medical judgement, and that judgement is exercised negligently, the HMO cannot be allowed to claim that the decision is solely responsible for the damage that results".

Also in the fall of 1999, California Governor Gray Davis signed the bill that will allow patients to seek punitive damages from HMOs for negligence.

Also in the fall of 1999 (a season to remember), the U. S. Supreme Court assigned itself a role in the debate of managed health care by accepting a case on whether an Illinois health maintenance organization breached a legal duty to a patient whose appendix burst in an eight day weight for a test to diagnose her abdominal pain.

The case had been reviewed by the Seventh District U. S. Court of Appeals. In its ruling, the Seventh District Court said that health maintenance organizations and the doctors are bound by a duty under ERISA provisions to act as fiduciaries, that is, to act "solely in the interest in the participants and beneficiaries" of an employer provided medical plan. By rewarding doctors for holding down costs, according to the court, the HMO may have placed doctors' interests in conflict with the interests of their patients.

Chapter 8

(16)NEJM, 336 &endash; 390, 1997

Chapter 10

(17)Our opinions on this chapter are clearly those of active participants in the events so that the total content of the Chapter should be taken as the perception of those who were against managed care practices.

(18)Much of the content in Chapter 10 was discussed quite cogently by T. Bodelheimer, M.D. and K. Sullivan, J.D. in their excellent health policy report "How Large Employers are Shaping the Health Care Market Place" (The New England Journal of Medicine. 338: 1005-1007, 1998).

Chapter 12

(19)The description of the Managed Behavioral Health Conference in Washington, D.C. in May 1994 is taken from the article "Managed Behavioral Health Care Charts a New Course" published in Psychiatric Times in July 1994.

(20)In October 1999, the Associated Press reported on its poll about the issues that American people most wanted to hear discussed during the 2000 Presidential Campaign. They were health insurance, the proper use of U. S. Troops, and the future of Social Security and Medicare.

(21)The quotation from Dr. Sharpstein is from the article "Changes Necessary to Insure Future of Psychiatric Hospitals" published in Psychiatric Times October 1990. Dr. Sharpstein was one of the first psychiatric leaders to use the terms "mangled care". His credentials as a clinician very willing to protect the patients under any circumstances are beyond challenge. That he was writing as if we should prepare ourselves to work under occupation terms was taken by some as a "compromising" position as opposed to the position of total rejection proposed by Dr. Eist. A major difference between Dr. Sharpstein and Dr. Eist may have been that Dr. Sharpstein was the CEO of a large hospital and Dr. Eist was in private practice.

Chapter 13

(22)One of Dr. Kassirer's best editorials (New England Journal of Medicine. 339: 1543 &endash; 1545, 1998) describes very vividly the doctors discontent of the late 1990s. Dr. Kassirer presents in somewhat different words an issue that we have addressed before: "One thing we know: Disgruntled, cranky doctors are not likely to provided outstanding medical care. Payors, insurers, and legislators must recognize this predicament and stop pretending that doctor discontent doesn't matter."

(23)We may continue to disagree as to what Dr. Eist's main achievements were. He had an 800 number to communicate with the members. Some of his successors preferred to communicate by e-mail. Dr. Eist improved relationships with the American Psychological Association, had more meetings of the Board of Trustees of the APA, was often applauded for long periods by enthusiastic audiences. This chapter does not record these events but records others that we consider more lasting.

Chapter 17

(24) JAMA. 282: 159, 1999.

Chapter 18: 18.2

(25)Herzlinger, RE. Market &endash; Driven Healthcare. Who Wins, Who Loses in the Transformation of America's Largest Service Industry. Addison &endash; Wesley Publishing Company, Inc., Reading, Massachusetts, 1997.

main | table | intro| 1 | 2 | 3| 4 | 5 | 6 | 7 | 8 | 9 | 10 | 11 | 12 | 13 | 14 | 15 | 16 | 17 | 18 | *

©2000 Munoz and Eist, The People v. Managed Care


main \| table \| intro\| 1 \| 2 \| 3\| 4 \| 5 \| 6 \| 7 \| 8 \| 9 \| 10 \| 11 \| 12 \| 13 \| 14 \| 15 \| 16 \| 17 \| 18 \| *

	Notes

	Chapter 1

	1)This chapter has gained much from "Integrated Mental Health Services" edited by William R. Breakey, Oxford University Press, New York, 1996.

	Chapter 2

	(2)"The Rise and Fall of the State Hospital" by William R. Breakey, is a chapter in "Integrated Mental Health Services1. In this chapter, Dr. Breakey comments that progress in the care of the mentally ill has been cyclical. Dr. Breakey outlines the events from colonial times that preceded current situations. A vivid portrayal of the conditions prevailing in mental health facilities by mid-20th century is contained in "The Turning Point" by Alex Sareyan, American Psychiatric Press, Washington, D.C., 1994. This book gives a description of the work of conscientious 1objectors during World War II. Their commitment led to important reforms in public mental health hospitals throughout the U.S., and laid a solid foundation for change in the care of the poor mentally ill in the country.

	(3)Henry Ford's ideas about his "poor man's hospital", Henry J. Kaiser's plan to capitate his workers, and health care cooperatives are as those proposed by Shadid and others, are discussed in "Capitation, Integration, and Managed Care" (JAMA. 275: 947 &endash; 962, 1996.) Our intention in this chapter was to establish a contrast between the early efforts in community health care and the new managed care industry. As pointed out in the 1996 article, even the Kaiser experiment was intended to offer "physicians more autonomy than was allowed by the salaried model".

	(4)JAMA (275, 957, 1996)

	Chapter 3

	(5)"The Doctors Mayo" by Helen Clapesattle (Pocketbooks, New York, 1968, is an extraordinary and readable account of the major changes that occurred during the period the Doctors Mayo practiced medicine.

	We chose to stress the Doctors Mayo because they presided on a major transformation of medical practice in a relatively short time. A more formal explanation of events and change can be obtained in "The Growth of Medical Thought" by Lester S. King, (The University of Chicago Press, Chicago, 1963).

	A major difference between physicians and the entrepreneurs that have come in with managed care is that the physicians have often put themselves and their lives on the line in order to help their patients. An extreme example is presented by Dr. Werner Forssmann, in his book "Experiments on Myself" (Saint Martin's Press, New York, 1974). Dr. Frossmann describes in the book how he as a 25-year-old interns in a small hospital in Germany, inserted a catheter into a vein in his left arm and directed it up into his heart. This experiment, done without anesthesia, and recorded by x-ray photography, opened the way to modern heart catheterization.

	Chapter 4

	(6)The partnership between cardiologist, Paul Dudley White, and psychiatrist Mandell Cohen, is well documented in the book "Doctor Heart &endash; The Life and Prescription for Living of Paul Dudley White, the World's Premier Cardiologist" by Paul Ogelesby, (Harvard University Press, 1986).

	After his pioneering work on anxiety disorders, Dr. Cohen went on to mentor Eli Robins, who organized and led the team that created diagnostic categories today widely used as part of the DSM process.

	Chapter 5

	(7)"Health Insurance and Psychiatric Care: Utilization and Cost" by Louis S. Reed, Evelyn S. Myers, and Patricia L. Scheidemandel (American Psychiatric Association, Washington, D.C., 1972) has acquired historical significance because it gives an account of the costs of mental health care before the emergence of managed care. These costs were much lower then than the cost today under managed care. One can claim that the enormous decrease in services under managed care has only damaged quality without decreasing costs.

	(8)Dr. Elwood's 1966 formulation is contained in his article Quantitative Measurement of Patient Care Quality Part II, a System for Identifying Meaningful Factors, Hospitals 40: 59-63, 1996.

	(9)During the dominance of managed care, Dr. Paul M. Elwood, and Dr. Alain C. Enthoven became public figures who often gave opinions and wrote articles on managed care. In our view, the best presentations they made were the Shattuck lectures. Dr. Enthoven gave his lecture in 1978 (The New England Journal of Medicine 298: 1229 -1238, 1978). Dr. Elwood gave his lecture in 1988 (The New England Journal of Medicine 318: 1549 -1556, 1988). Though these lectures represented the core of their thinking, they probably do not reflect their thoughts as of today. More recent writings would indicate that both Dr. Elwood, and Dr. Enthoven are prepared to react to new realities. We take their stand on pre-tax medical savings accounts as a demonstration of the evolution.

	(10)Dr. Elwood's comments on how his vision was derived are contained in an interview published in Medical Economics on May 13, 1996. The title is "How Doctors Can Regain Control of Health Care".

	(11)The comments on pre-tax MSAs contained in "Responsible Choices:The Jackson Hole Group Plan for Health Reform" by Doctors Elwood and L. Tobin (Health Affairs Summer 1995: 24-39).

	(12)The Shattuck lectures were considered by many as "classics". Not less "classic" was the article "The Monetarization of Medical Care" by Eli Ginzberg (The New England Journal of Medicine 310: 1162 &endash; 1165). The last paragraph of this article appears extremely timely today. "To secure its long-term financial foundation, American Medicine will require a combination of political leadership and professional cooperation that is not yet visible on the horizon. The great danger is that such cooperation will be delayed past the point at which intervention can be effective."

	(13)Events in the 1990s have proven that positions presented by William B. Schwartz, M.D., in his paper "The Inevitable Failure of Current Cost Containment Strategies", (JAMA 257: 220 &endash; 224, 1987) were right on target. Dr. Schwartz position was a direct response to Dr. Enthoven's opinions. Dr. Enthoven had expected that costs would be controlled by eliminating care that was presumed to be of no medical value. Even accepting that there was unnecessary care at the beginning, which has not been proven, the decrease in services that have accompanied managed care has not reduced costs. If one considers increases from the time-managed care started, there has been an increase in costs of more than 700%.

	Chapter 7

	(14)Wendy K. Marinerer, J.D., M.P.H., wrote "State Regulation of Managed Care and the Employee Retirement Income Security Act", (The New England Journal of Medicine 335: 1986 &endash; 1990, 1996). The whole fourth paragraph of this chapter is a direct quotation from that article. Dr. Marinerer's opinion has been expressed in Congress many times "as long as States are charged with regulating private insurance, Congress should amend ERISA to permit them to regulate managed care, whether or not it is provided through an ERISA Plan".

	(15)Dr. Welch's analysis was published under the title "Manage Care Litigation: The Foundation is Laid" the Psychiatric Times, August 1999 (pages 11 and 14). In the fall of 1999, the Illinois Supreme Court ruled that patients can sue health maintenance organizations for malpractice, the claim that decisions on what treatment the companies will cover amount to medical care. In the decision, Chief Justice Michael Bilandic wrote "Where an HMO effectively controls the physician's exercise of medical judgement, and that judgement is exercised negligently, the HMO cannot be allowed to claim that the decision is solely responsible for the damage that results". Also in the fall of 1999, California Governor Gray Davis signed the bill that will allow patients to seek punitive damages from HMOs for negligence. Also in the fall of 1999 (a season to remember), the U. S. Supreme Court assigned itself a role in the debate of managed health care by accepting a case on whether an Illinois health maintenance organization breached a legal duty to a patient whose appendix burst in an eight day weight for a test to diagnose her abdominal pain. The case had been reviewed by the Seventh District U. S. Court of Appeals. In its ruling, the Seventh District Court said that health maintenance organizations and the doctors are bound by a duty under ERISA provisions to act as fiduciaries, that is, to act "solely in the interest in the participants and beneficiaries" of an employer provided medical plan. By rewarding doctors for holding down costs, according to the court, the HMO may have placed doctors' interests in conflict with the interests of their patients.

	Chapter 8

	(16)NEJM, 336 &endash; 390, 1997

	Chapter 10

	(17)Our opinions on this chapter are clearly those of active participants in the events so that the total content of the Chapter should be taken as the perception of those who were against managed care practices.

	(18)Much of the content in Chapter 10 was discussed quite cogently by T. Bodelheimer, M.D. and K. Sullivan, J.D. in their excellent health policy report "How Large Employers are Shaping the Health Care Market Place" (The New England Journal of Medicine. 338: 1005-1007, 1998).

	Chapter 12

	(19)The description of the Managed Behavioral Health Conference in Washington, D.C. in May 1994 is taken from the article "Managed Behavioral Health Care Charts a New Course" published in Psychiatric Times in July 1994.

	(20)In October 1999, the Associated Press reported on its poll about the issues that American people most wanted to hear discussed during the 2000 Presidential Campaign. They were health insurance, the proper use of U. S. Troops, and the future of Social Security and Medicare.

	(21)The quotation from Dr. Sharpstein is from the article "Changes Necessary to Insure Future of Psychiatric Hospitals" published in Psychiatric Times October 1990. Dr. Sharpstein was one of the first psychiatric leaders to use the terms "mangled care". His credentials as a clinician very willing to protect the patients under any circumstances are beyond challenge. That he was writing as if we should prepare ourselves to work under occupation terms was taken by some as a "compromising" position as opposed to the position of total rejection proposed by Dr. Eist. A major difference between Dr. Sharpstein and Dr. Eist may have been that Dr. Sharpstein was the CEO of a large hospital and Dr. Eist was in private practice.

	Chapter 13

	(22)One of Dr. Kassirer's best editorials (New England Journal of Medicine. 339: 1543 &endash; 1545, 1998) describes very vividly the doctors discontent of the late 1990s. Dr. Kassirer presents in somewhat different words an issue that we have addressed before: "One thing we know: Disgruntled, cranky doctors are not likely to provided outstanding medical care. Payors, insurers, and legislators must recognize this predicament and stop pretending that doctor discontent doesn't matter."

	(23)We may continue to disagree as to what Dr. Eist's main achievements were. He had an 800 number to communicate with the members. Some of his successors preferred to communicate by e-mail. Dr. Eist improved relationships with the American Psychological Association, had more meetings of the Board of Trustees of the APA, was often applauded for long periods by enthusiastic audiences. This chapter does not record these events but records others that we consider more lasting.

	Chapter 17

	(24) JAMA. 282: 159, 1999.

	Chapter 18: 18.2

	(25)Herzlinger, RE. Market &endash; Driven Healthcare. Who Wins, Who Loses in the Transformation of America's Largest Service Industry. Addison &endash; Wesley Publishing Company, Inc., Reading, Massachusetts, 1997.