RE: The Managed Care Malignancy (with Response by author)

Michael L. McCann, MD
Article Type: 
Winter 1997
Volume Number: 
Issue Number: 

Dear Editor,

I am a managed care physician, not by choice alone. Your editorials such as “The Managed Care Malignancy” by Vernon L. Goltry, M.D. are too one-sided. The world of medical care is not black and white. The “private sector,” which had generations to perfect its modus operandi, has to accept some irresponsibility, primarily for its lack of leadership and control.

When I was a fledgling pediatrician full of the Hippocratic ethic, I did things I thought were in the best interest of my little patients — like not taking unneeded x-rays to confirm a pneumonia which was already clinically evident, or not taking x-rays on every little finger sprain or greenstick fracture. Imagine my surprise when I was called on the carpet by the MD Chief who admonished me for “not putting enough x-ray revenues on the books.” Besides that, since this was a deviation from standard practice, it might not be good medicine. By contrast, today, as a managed care physician, I am encouraged to do exactly the opposite with statistics to show that fewer unneeded x-rays actually may be better.

Another example: When salesmen try to get us to increase the profitability of our practice by taking a cardiogram or pulmonary function test on all referrals, they find it hard to understand our mind-set, that we do not want to drive up the cost of care needlessly by ordering procedures readily reimbursed by third-party payers — but entirely unneeded. The patient is not trained to know the difference. The patient thinks the doctor is being thorough, whereas, the physician is really being influenced by the “bottom line.”

I attended a seminar recently in which the main point was to show doctors how to bill the insurance company for 75 instead of 15 routine skin tests we do for allergy screening. Who in the private sector monitors these practices? Should the fox alone be in charge of the chicken coop?

I paid my dues to the AMA for many years and never did I even hear a discussion of these ethical problems. Well, third-party payers are the cause of it all, right? So how unrealistic can anyone be not to realize the necessity of an insurance plan, universal in my book, to cover the costs of our high-tech care that is out of the reach of all but the very wealthy. The debate today should be over who controls these insurance plans, the public or a few greedy individuals as witness the deplorable attempted sell-out of one of Ohio’s Blue Cross plans to benefit by millions of dollars only a hand full of Blue Cross executives. There ought to be a law, or at least a policy.

To be sure, the deficiencies in managed care are being uncovered. For your readers information, we physicians who work in managed care are not lackeys of the administration, but activists on behalf of our patients. We are constantly doing battle with administrators, both MDs and non-MDs, pharmacists, and others who attempt to interject themselves into the physician-patient relationship. So far, I have yet to lose a battle when the patients’ best interests are at heart. I have been wrong, too, like all mortals, and though irritated, have had to concede there may be a better and cheaper way to do a certain task.

What I am trying to say is that your one-sided rhetoric is non-productive and anachronistic. If you and yours are truly interested in the Hippocratic Oath, then encourage dialogue from all of those interested in helping our fellow humans in a way that addresses real, present-day problems. It is a whole new ball game that needs new rules and penalties which have stood the test of time and to which all participating parties agree. Lets have some ideas for solutions to present-day problems from the AAPS, not a retreat to the long-gone good old  horse and buggy days.

Michael L. McCann, MD
Kaiser Permanente
Parma, OH


Dr. Goltry Responds:


I certainly agree with Dr. McCann that the private sector has not done its job in establishing a sound method of medical care delivery and payment.

However, I believe history shows us that the initiation of the error began some 40 to 50 years ago at the end of World War II. Employers attempting to recruit top employees in the face of wage and price controls left in place by the federal government sought other ways of attracting workers. One of the ways they settled on was competing with each other by providing attractive health care benefits. So was born a wholesale rush into employer-provided, prepaid (for the most part) medical care that was not treated as wages. This put somebody other than the patient in the position of paying for his medical care, violating a basic free market principle and setting the course for out-of-control medical care costs that has matured into the present-day situation.

True insurance (coverage for unforeseen catastrophic events) in the medical field slid into the phenomenon of prepaid medical care and away from the basic premise of insurance as is the case in homeowners and automobile liability in protecting against financial catastrophe. The patient ceased to be a prudent shopper, and the physician and the rest of the medical care delivery system, hospitals, etc., were relieved of the one-on-one pressure the patient, as a prudent shopper, would otherwise exert on them in a truly free market environment. The patient loved it. The physician loved it. The hospitals loved it.

The insurance companies and employers subsequently suffered the consequences of this fundamentally flawed arrangement. As long as the patient is separated from medical care costs and the financial responsibility of the transaction, he doesn’t care what his medical care costs. Now with managed care rationing and the denying of medical care for profit (inherent to the system, particularly capitation which is managed care brought to full maturity), there is a very real threat to the very existence of medicine as a profession.

In my view, the only way this terrible 50-year-old error can be remedied is through the Medical Savings Account (MSA) concept coupled with a high-deductible catastrophic policy to cover the expensive technology you address and to place the patient in the position of paying for his own medical care. The primary goal of the physician would then be his adherence to the principles of the Oath of Hippocrates in which his individual patient’s welfare is above all else.

With our patients in control of medical care costs — not the insurance companies, managed care companies, or physicians — proven, free market principles would be in operation. The patient would become a prudent shopper, controlled by no one.

I recognize it is a very painful situation for one to be economically and otherwise entangled in a managed care system in order to survive. And, I am not saying that getting out of this is going to be painless or without personal cost. But then, when you look at the future of continuing in this position of empowering a system that tempts and fosters incredible abuse in the rationing of health care, employing the principle of denying health care for profit, the wholesale departure from the principles of the Oath of Hippocrates transferring allegiance from the patients to the managed care companies and other third-party payers — where does that leave us? The physician has essentially relinquished his mind, his tool of production, into the hands of a third party.

The medical profession in assisting in the empowerment of patients through the MSA concept sets its patients free and in the process becomes free itself.

Again, I appreciate Dr. McCann’s concerns and his frustration. The foundation of payment for medical care must be changed, and the patient empowered to control his medical care costs. At the present time, the MSA coupled with a catastrophic insurance policy, not managed care, appears to be the only way to achieve this end.

Vernon L. Goltry, MD
Boise, ID

Originally published in the Medical Sentinel 1997;2(1):3-4. Copyright ©1997 Association of American Physicians and Surgeons.



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