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Ann Thorac Surg 1996;61:6-7
© 1996 The Society of Thoracic Surgeons
President, The Society of Thoracic Surgeons
``Managed care'' means many things to many people. To many patients the term implies complete health care either with the security of prepayment in a health maintenance organization or through another type of plan that provides needed health care while it contains costs. To private and government health insurance carriers ``managed care'' gives a license to govern expenses by telling providers (physicians, outpatient facilities, and hospitals) and patients what payments and services are allowable. Financial incentives motivate private insurance carriers, and for government the drive is to balance the budget. In both cases the bottom line is money. Cost rather than quality is the driving force. We are living through a managed care revolution.
I have the privilege of heading a wonderful family and leading The Society of Thoracic Surgeons (STS) during the revolution. As family father I have seen my son's health care delayed when his gatekeeper general physician did not call a needed specialist. When I asked for specialty consultation I was told by the gatekeeper that I did not seem to understand what my son's insurance policy provides. As your president I have had an accelerated learning experience about the political process that surrounds such things as conversion factors, CPT codes, practice expenses, resource-based relative value scales, and many other aspects of thoracic surgery that are outside of the art and science of our specialty. I see tyranny in managed care and I worry about its effect upon our patients and upon our ability to serve them well.
My thesaurus equates tyranny and totalitarianism. Two of the definitions of tyranny in my dictionary are ``oppressive and unjust government ...and unjust use of power or authority.'' Managed care is giving insurance companies and government totalitarian control of payment for health care. With alarming and increasing frequency there is unjust use of the power of the purse.
The American Revolution, World War II, and the fall of ``McCarthyism'' prove that Americans will not tolerate tyranny. With such a splendid history of successfully defending freedom, why are Americans tolerating the managed care revolution, which is rapidly eroding our freedom?
The public does not understand the consequences of what is ongoing. Most Americans are well and busy and productive. They begin really to concern themselves with the details of health insurance when they or members of their family take ill. When the benefits of health insurance are needed most, sickness consumes patients and their families. Then they do not have the energy, the time, or the money to resist effectively. Most politicians take the short-term view: balance the budget and secure reelection. Considerations of quality, providing for education, and allowing research are diffuse intangibles that are difficult to define and amenable to being deferred or ignored. Thus, neither the public nor its legislators are opposing the principles of managed care.
The privilege of STS leadership has taught me many things, including the following: (1) Thoracic surgeons possess incredible energy and ability to achieve goals. (2) The political process is very demanding. (3) Despite our specialty's many contributions to medicine, we are small fish that engender little political sympathy and much hunger in a big pond in which there are barracudas.
At the close of my term I thank the STS membership, the Council, the Executive Committee, and the various STS committees that have specific missions for their superb work. I did not fully appreciate the enormous talent and dedication that exists within our specialty. Many gifted men and women have contributed generously toward our developing a strategic plan that includes the following areas: (1) definition of our specialty so that the public, our colleagues in other medical fields, and insurance companies will understand us better; (2) workforce considerations to assist with planning for the future; (3) outcome evaluation through database work to help ourselves and others assess the value of our work; (4) cost containment efforts to help our membership make responsible practice changes that will save money; and (5) education planning to ensure new generations of excellent thoracic surgeons. I hope this emerging plan will be accepted by the Council as a guideline for the near future, and that it will be revised again and again in the long-term as changing needs require.
I take the liberty of suggesting that we should do the following during the ongoing managed care revolution: (1) keep our primary focus upon excellence; (2) insist that freedom is a fundamental necessity and right for our patients and for ourselves; (3) resist forces that splinter our specialty locally and nationally; (4) work with allied specialists toward the unification of multidiscipline thoracic service units; (5) be as modest as reason will permit in accepting lesser incomes; (6) resist and contain the forces of tyranny; and (7) be constructively proactive as needed change moves forward, eg, lead in the containment of costs, in workforce planning, and in the distribution of resources.
As a small succulent fish in the barracuda-filled pond of the managed care revolution we have less influence than many of us have thought. We can educate and enroll our patients as allies because they and their families magnify our influence. We should take the time to advise our patients of the benefits of freedom of choice in health care and of the need for education and research. The reality of limited resources creates the necessity for change. Nonetheless, the highest possible quality of health care, including access to specialty care, is a right. Tyranny is unacceptable.
Footnotes
Address reprint requests to Dr Benfield, Department of Surgery, University of California Davis Medical Center, 4301 X St, Sacramento, CA 95817.
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