The Consequences of Managed Competition; V. Cangello, M.D.

Unlike the people in toll booths on the New Jersey Turnpike, managed-care gate keepers don't collect the toll. But that doesn't mean that nobody pays. Even if we abolish payment at the time of service, medical care must still be paid for. The only choice is to pay in advance or to pay later. With government programs, we THEFREEMAN IDEASON LIBERTY often borrow money and commit our great grandchildren to pay. Another problem with the freeway is that you can only go where the freeway goes. If there's a roadblock at your exit, you can't take that exit. Countries that promise "universal ac cess" are pretty good at paying for well baby checks and vaccines and doctor visits for the common cold. Those are exactly the things most people are able to afford for themselves. The roadblocks are at the exits that lead to the hospital. The global budgeters "con tain costs" -ration health care-by deny ing those things that you do need insurance to pay for: heart surgery, radiation treat ments for cancer, hip replacements, things like that. Out of "compassion," reformers may open another exit: the one that leads to the cemetery. Do you think it's accidental that euthanasia and "universal access" are on the agenda at the same time? When government gets involved in providing health care, health care must be rationed.

If you want to see reality, don't look at Disneyland. Look at the Santa Ana Freeway. D THE CONSEQUENCES OF MANAGED COMPETITION by Vincent W. Cangello, M.D. U nder managed competition the primary care physician takes complete charge of the patient's health care. The primary care physician is encouraged, and often finanDr. Cangello is a private practitioner in Oakland, California. cially rewarded, to limit and reduce the number of patients he refers to a medical or surgical specialist. Under managed competition, a female patient, for example, loses her prerogative to see a gynecologist unless she first obtains THE CONSEQUENCES OF MANAGED COMPETITION 437 the permission of her primary care physician to make such a visit. The limiting of referrals, a basic concept of managed health care, is in direct conflict with the structure of American medical education and the medical profession. Such limits can cause primary care physicians general practitioners-to prescribe care at levels that exceed their knowledge and training. When this occurs, the patient runs the risk of receiving improper care.

Evidence of this was provided by Amer ican Medical News on September 14, 1992, when it was reported that malpractice law suits filed against primary care physicians is on the rise while those against surgical specialists is declining. Timothy Morse of St. Paul Fire and Ma rine Insurance Company, which insures 30,000 doctors in 43 states, told American Medical News that "Well over 50 percent of our claims made and over 65 percent of all our claims paid are coming from failure to diagnose and improper treatment. " Medical patients should know that the body of medical information facing today's medical students is so immense that it is virtually impossible for anyone doctor to become expert and stay abreast of all its advances. Physicians specialize in order to master a subject, not merely in order to make more money, as they are often accused. Such an accusation fails to show appreciation for and gives no credit to the students who choose to be specialists for the "security of mas tery" or for the enjoyment of the work involved.

Americans today want the best care avail able, regardless of cost and despite any reluctance to reform bad health habits. They willbring suit against the doctor ifthey don't get it. With that reality in mind, medical students who choose to become primary care physicians are taught to respect the limits of their ability and to seek the benefit of consultation with medical and surgical specialists, without hesitation, whenever necessary. This basic tenet of the American medical training, which has produced a quality of health care envied throughout the world, is discouraged by the "primary care/gate keeper" concept of managed competition. A review of British medical history dem onstrates that any reduction of communica tion between primary care physicians and their consultants leads to the separation and eventual isolation of the primary physicians and guarantees an overall lowering of the quality of health care available to their patients.

Frank Honigsbaum, an American physi cian, studied these phenomena and wrote in his report "Division in British Medicine" (Kogan Page Ltd., 1979): "To the world outside, the medical profession [in England] appears to form a unitary whole." In reality, however, "Doctors nearly every where are divided into two main classes-General Practitioners and Specialists-and the gap between them grows wider every year. For this, the advances in knowledge are mainly responsible. " He emphasized that' 'It is the ongoing intellectual partnership and ex change of knowledge occurring between the generalists and specialist [the traditional practice in the U.S.] that keeps the quality of medical care at its best." If this partnership is disturbed, as it was in the British National Health Service, the quality of care diminishes throughout the system, and especially at the primary care level. A correct diagnosis and proper care at the outset of a patient's illness will do more to reduce the cost of care than any restriction ofappropriateconsultation.It wouldbe better to err on the side of an unnecessary consul tation than not to have one at all. D THEFREEMAN IDEASON LIBERTY THE COMING FINANCIAL COLLAPSE OF SOCIAL SECURITY by Peter J. Ferrara T he first officially recognized financial collapse of Social Security occurred in 1977. Government projections at that time showed, and everyone agreed, that without major changes Social Security would be unable to pay all of its promised benefits within a couple of years, with a yawning, continually growing deficit after that time.