Managed care, the good guy.

As has been noted before in this space, long-term care has always had a somewhat perverse relationship with managed care. At a time when managed care was moving to dominate hospitals and physician practices, long-term care stood serenely off to the side. Oh, there were the occasional PACE and SHMO demonstrations, and that brave Senior Options program in Minnesota, but they were small and far between. Long-term care remained relatively untouched and unconcerned.

But then change loomed. It was becoming clear that, as managed care proceeded to take over healthcare, long-term care facilities would have to get ready. Pretty soon they would be wanting, and even needing, those managed care contracts, and they would have to restructure their business and clinical operations accordingly - probably sooner rather than later.

Meanwhile, though, managed care was beginning to assume the role of political villain. People were noticing that it was big, but more than that, it was impacting upon their healthcare and lives in sometimes unpleasant ways. Actress Helen Hunt's anti-HMO story in As Good As It Gets - and the less famous but equally poignant revelation by William Hurt in The Doctor, that the MRI that could have caught Elizabeth Perkins' brain tumor in time had simply been "too expensive" to perform - had movie audiences booing and hissing. Managed care went on to assume the role of bad guy in many a popular joke. Congress, for its part, twisted itself into the usual pretzel trying to figure out how to punish managed care without anybody's losing votes or money.

Before moving on to the latest twist in the strange saga of managed care and long-term care, permit me a personal reflection. I remember interviewing, many years ago, Dr. Donald Ross, cofounder of the Ross-Loos Clinic in Los Angeles and one of the 1930s pioneers in what was then called the "prepayment" movement, the progenitor of today's HMOs. No wide-eyed radical, he, but a solidly four-square surgeon then in his early 80s, Dr. Ross told me how he and his partner, Dr. Clifford Loos, had been ostracized by the California Medical Association for many years. Though their basic idea had been to make healthcare more accessible and affordable for various California labor unions, former physician colleagues cast aspersions on their characters; perhaps they were Communists! Dr. Ross remembered consoling his troubled partner with a Biblical verse: "Father, forgive them, for they know not what they do."

How things have changed since those lonely days. Managed care (in today's version) is now the Establishment, and in the eyes of some, a big bad one at that.

But wait! Not in all quarters, as it turns out. Managed care indeed has a shining, sunny face - is, in fact, preferable to the status quo - in at least one segment of today's healthcare. You guessed it, in long-term care.

How could this be? Take a look at the article in this issue on the Momentum Health Alliance (p. 24), where President Michael Barber, MD, compares the managed care business his alliance is developing with the Medicare Prospective Payment System. Dr. Barber can correct me if I'm wrong, but I get the impression he would rather chew nails than have much to do with PPS. Compared to PPS, managed care looks positively benign, both in its finances and its relative freedom.

So, there you have it: PPS making managed care look good, even in its darkest days. Once again, long-term care stands alone.