In evaluating managed care, the critical issue is its effect on how patients and their doctors make medical decisions. At the heart of the Catholic approach to health care is a personalist philosophy that treats the human person as the focus of all decisions. The genuine welfare of the person—both spiritual and physical—must be the preeminent criterion for health care decisions. Since patients and their families are morally accountable for their decisions, they must have genuine autonomy to make choices, as well as adequate information and a full range of options. Financial concerns may be relevant in determining whether a course of treatment is ordinary or extraordinary, but the ultimate decision must rest with the patient and his family and must be directed to the best interests—medical and moral—of the patient.
Managed care approaches medical decision-making very differently. Ultimately, it is based on a calculus of risk and cost, made by persons who are ignorant of the particularities of a case. This cost-based approach serves mainly the financial health of the insurance company, increasing profitability by limiting the number of procedures covered. This alone is enough to raise grave concerns, because a system whose decisions are divorced from individual circumstances and the best interests of patients is fundamentally inconsistent with a personalist approach to health care.
Managed care also removes information and autonomy from patients, their families, and doctors in making medical decisions. Strictly speaking, the insurance company does not make medical decisions. In reality, however, managed care restricts patients’ medical options in several ways: (a) companies decline to pay for procedures that the patient cannot afford privately, effectively removing some procedures as options; (b) doctors, who receive financial incentives from the insurance companies for reducing costs, have divided loyalties that may influence their judgment; and (c) the fiscal pressures on health care institutions may result in reductions of staff and services, further reducing patient choice and quality of care. Given the way that managed care systems work, critical health care decisions are made not by patients or their doctors, but by insurance company employees. (These criticisms are not made merely by Catholics, but are voiced industry-wide.)
Most disturbing is managed care’s built-In incentive to reduce expensive end-of-life care, which may force patients to forgo morally obligatory treatment. In essence, managed care may be equivalent to passive euthanasia.
According to an article in the September 1997 Journal of the American Medical Association, managed care patients in intensive care units received 25% less life-prolonging treatment than fee-for-service patients, and experienced a 8% higher death rate after 100 days and a 9% higher death rate after one year. An accompanying editorial study raised “the possibility that, in addition to its effect on limiting expensive, ineffective care, managed care may also limit potentially effective life-saving treatments. . . . If a patient’s family requests expensive, technological low-yield care and a health maintenance organization refuses this care, does this reflect high quality care?”
The real danger is borne out by the experiences of those who have worked in the system, and was put very starkly by Dr. Linda Peeno in her 1996 testimony before a House subcommittee. Dr. Peeno, who served as reviewing physician for a managed care company, opened her remarks with the chilling statement that she “caused the death of a man” by rejecting coverage for a necessary, heart operation. She stated that “managed care maims and kills patients” by denying necessary treatments for economic reasons. Her testimony illustrated that under managed care, decisions are really made by companies whose financial interest is inherently in conflict with the patient’s interests. Dr. Peeno concluded that “managed care . . . is inherently unethical in its organization and operation.”
Health professionals have consistently complained that managed care interferes with their relationship with their patients and distorts the delivery of treatment. Surveys also indicate that many doctors have had necessary procedures denied to their managed care patients, raising substantial questions about the quality of care. There have been reports that women in particular are not well-served by managed care plans, especially when their needs go beyond routine preventive treatments. One doctors’ organization has said, “Inevitably, managed care puts patients in an automatic conflict of interest with their physicians, whose livelihood is controlled by the corporation. Availability and quality of medical services must be sacrificed.” This means, of course, that vulnerable, expensive human lives will be sacrificed.
Catholic health institutions and professionals are certainly committed to ensuring the best quality of care. But there is no reason to believe that a Catholic managed care system will be any less financially motivated in its decisions, or that ethical conflicts will be lessened. As a result, the conclusion is inescapable that the principles and practice of managed care are fundamentally incompatible with a Catholic approach to health care and to the defense of human life at all stages.
Given the dangers of managed care, we must ask if there is a credible alternative, any safe harbor in which the Church, Catholic health professionals, and Catholic patients can be assured that their religious values will be respected and supported, and where the focus of care will be on the human person, not the bottom line.
It is clear that a safe harbor cannot be established under managed care. One credible alternative would be a system based on a medical savings account (MSA). Under this arrangement, you purchase a high-deductible insurance policy, your employer pays into a MSA to cover the deductible, and you can spend that sum until the deductible is reached, at which point the insurance policy will cover all additional costs. If there are any funds left in the MSA at the end of the year, you keep them. If you are indigent, the government would purchase the policy and contribute to the MSA; if there is any money left over in the MSA, the government is reimbursed.
The advantages of the MSA are that it gives full autonomy to patients in their medical decisions, and permits them to seek medical treatment that is consistent with their moral values. No decisions are made by health plan administrators, and no choices are artificially restricted by cost or risk factors. Since the decision-making power is left with individuals, there is less room for government interference through regulation.
The second option is health insurance cooperatives (called “reciprocal interinsurance associations”). You join a cooperative venture that provides you with health insurance, with the possibility of reimbursement if the cooperative has a surplus. If you are indigent, the government pays to enroll you in the cooperative. The principal advantage offered by a cooperative is that control of medical decisions is left in the hands of the individual, and the policies of the cooperative are controlled by its members.
Both of these systems are far superior to managed care in their respect for Catholic principles. The principle of subsidiarity strongly favors the MSA or cooperative approach. They would encourage openness and partnership between patients and their doctors and hospitals. Neither system would limit medical decisions based on cost. Most importantly, they would restore the primary focus of medical decisions—the best interests, spiritual and physical, of the patient.