Sustainability as the lynch pin of public policy and industry initiatives. (The Next Challenge for Managed Care).

THE INVITING INVESTOR-PROFIT U.S. HEALTH CARE model unfortunately offers, simultaneously with the promise of rich reward, the opportunity to inadvertently kill the golden goose by falling to tend to her basic needs.

Between 1914 and 1965, four presidents (Wilson, Truman, Johnson, and Nixon) urged Congress to establish a uniform policy defining health care as a right of U.S. citizenship.(1) A fifth president, Franklin D. Roosevelt, fearing defeat of his entire "social security" program, cut health care benefits out of his proposals to Congress.

In 1965, existing Medicaid and Medicare programs came into being as a result of political compromise. That is, the customary and moral right to health care was legislated only for defined segments of the population. These "entitled" groups included people deemed most in need of health care services, such as the elderly, indigent mothers and children, and those with certain specified medical conditions. Other U.S. citizens were left to fund needed medical services themselves, with the help, in most instances, of private insurance and/or employee health care benefits.

This patchwork non-system resulted in a complex maze of "third party payer" rules and regulations to be dealt with by hospitals, the primary recipients of health care dollars. So governing boards increasingly selected the chief financial officer as the best-suited person to fill the job of "administrator."

By the 1980s, this generation of Wall Street-wise CEO-financiers had wrested local control of health care from owners such as churches, physicians, and local boards. They replaced terms focusing on professionalism with language designed to emphasize the organization, its executive, and the primary goal of maximizing profit. Thus "patients" became "customers," "administrators" became "executives," and "clinical services" became "product lines."

New expense items appeared in the budgets of this new breed "health care organizations." These expenses included seven-figure "marketing campaigns," billboards, radio and TV commercials, generous fees to management consultants, accountants, and attorneys, and escalating salaries for increasing numbers of executives in additional management layers.

This approach to health care as a bureaucratic business doing "whatever it takes" to maximize profit matched the Reagan and Bush administrations' belief in enriching entrepreneurs, who were then expected to "trickle down" benefits to both employees and consumers. The investor-profit model of health care, unique in the world, became firmly embedded in U.S. health care policy.

Statistics claiming that less money was being spent to care for each patient. client, or resident, and/or to provide "wellness" services, such as by "downsizing" professional staff and closing non-profitable care facilities, were accompanied by the emergence of a new national issue. That is, escalating executive salaries were totally out of balance with the level of workers' salaries, The public became restless and suspicious, because it wasn't hard to see where health care dollars were going.

By the early 1990s, a litany of problems with U.S. health care (2) became the battle cry of "reformers." Once again, a U.S. President attempted to persuade Congress to "re-form" (fundamentally change) the U.S. health care system. President Clinton's initiative was flawed from the first moment. On September 23, 1993. Clinton arrived to announce his plan to a joint session of Congress and a waiting nation, only to find the wrong speech on his teleprompter.

So the outcomes of the Great Health Care Reform Debate of 1993-94 were not hard to predict. The result was another rejection of health care as a legislated right for all U.S. citizens, a reinforcement of the profit-taking model of the 1980s now known as "managed care," and a few bones thrown to the public in the form of "quick fixes," such as a law prohibiting insurance companies from taking advantage of "pre-existing conditions" clauses to drop undesirable beneficiaries from their rolls.

So far, managed care has not lived up to its promises and potential. Admittedly, the health care system prior to managed care was a non-system. But its features included committed health care professionals, caring local institutions, freedom of choice, and laws reflecting public confidence. And it was based on the assumption that needed health care services are a customary, moral, and implied legal right of U.S. citizens.

In contrast, today's version of managed care is characterized by financial and legal manipulation, "choice" constricted by provider selection of physician panels, and laws reflecting lack of public trust. One such statute outlaws "gag orders." It was passed in response to the practice of forcing physicians to sign an agreement not to tell patients of needed but expensive diagnostic procedures and treatments. Another new law forbids too-early discharge from confinement of mothers and their newborns. A third law carefully defines rules under which public assets may be traded or sold, to prevent the raiding and raping of a community's health care resources by managed care "acquirers," who often close a needed facility shortly after acquiring it.

And today, organizational priority given to patients' rights and ethical issues is usually limited to meeting minimal requirements for these activities, such as those of the Joint Commission and to dilemmas related to incurable illness and the process of dying.

The biggest star in the crown of managed care creators is the movement toward integrated delivery systems. But so far, most "integrated systems" are integrated in name only, remaining loosely affiliated units focusing on personal gain through successful competition, as opposed to seeking reasonable profit by responding to the public's wish for truly integrated delivery systems focused on patient care. (2)

Thus, managed care's record does not bode well for its future, when the term is used to mean the profit-taking model of financing health care. Managed care has failed, so far, to put an end to worries about health care costs, how available money is used, and accessibility to dependable health care services. Indeed, the initial stimulus for all this dramatic change in the health care system was concern for the under-insured, the uninsured, the aging, those with economically and emotionally draining chronic illness, the dying, and the indigent. But today, thanks to managed care, concern that health care needs could threaten economic security and even lead to personal bankruptcy has spread to encompass the young, the healthy, the insured, longtime employees loyal to one company, and the relatively well-to-do.

Can managed care survive?

Managed care can survive its initial foolish years, if it heeds the voices of those urging that two priorities be reflected in public policy, legislative efforts, and business practices. One of these priorities is accountability for today's actions. The other is preserving this country's health care resources.

Jerome P. Kassirer succinctly summarizes this admonition: "These companies can survive, if (they) show that they care about more than profits, that they do not skimp on care, that they support their just share of teaching, research, and the care of the poor, that they no longer muzzle physicians, and that they offer something special (including controlling costs) by managing care." (3)

The need for accountability is being effectively articulated by those urging managed care to appreciate that the emphasis should be value (defined as dependable services provided at reasonable cost), rather than focusing only on costs and profits. But so far, little attention has been given to accepting responsibility for conserving this country's health care resources, rather than presiding over a deterioration of those resources because of failure to fund future needs for renovation, expansion, innovation, and human resources.

Concern tar the future

It Indeed seems time to wonder about eventual effects of government policies and business practices which encourage draining off huge personal profits at the expense of budget Items, such as research and development, medical and nursing education, orientation and training of personnel, and contingency funds to repair and/or replace depreciated and outmoded buildings and equipment. These items are increasingly hard to find as high priorities in the budgets of managed care organizations. (4)

There may be a parallel between existing health care policy and other short-sighted policies which fail to focus on the future. Without being alarmist, some predict the deterioration and even collapse of national parks, Interstate highways, major league baseball, the public education system, and the environment. Their common theme is the old Chinese proverb, "If we do not change our direction, then we are very likely to end up exactly where we are headed."

Ironically, adding preservation of resources to the agenda and budgets of managed care organizations would only reflect an Important key to success in business with which we already claim to be familiar. On W. Edwards Deming's famous list of 14 "Continuous Quality Improvement" principles, number one is, "Create Constancy of Purpose," defined as "rather than making money, a company's role is to stay in business...!" (5)

Sustainability" - an evolving concept

The need to strike a balance between seeking immediate profit and preserving available resources is not unique to health care. Indeed, "sustainability" is an emerging concept as a central public policy theme. The W.K. Kellogg Foundation's working definition of sustainability is "the ability to meet the needs of the present while simultaneously safeguarding resources and the well-being of future generations." (6)

This concept is illustrated in practical terms by the field of agriculture. (7) Farmers and ranchers face a basic dilemma, which is maximizing productivity and profit from the sale of animal, grain, and food products, while simultaneously safeguarding the ability to do the same thing next year, and the year after, and the year after that. That is, decisions to use some measures which might maximize today's yields must be tempered with concern for tomorrow's harvest. In November 1997, a national conference of farmers, community workers, ethicists, environmentalists, economists, and others--a group with interests every bit as diverse as those represented in the health care field--met to respond to the challenge for "an ethic of farming which includes attention to agriculture's impact on and integration with a wider world...a philosophy needed as much by those who farm as by those who eat." (8)

Apparently, U.S. agriculture has no clear production ethic and is in search of one. In contrast, U.S. health care policy, clearly if implicitly, states a production ethic: "Maximize profit." Thus. sustainability as a lynch pin of U.S. health care policy would indeed be a significant change.

Health care providers, professional practitioners, third-party payers, and users of health care services would all be well-served by a broader discussion of the impact of public health care policy than occurred in the Great Health Care Reform Debate of 1993-94. which focused only on selecting a mechanism for financing health care.

Call for a new national health care policy advisory commission

In the history of U.S. health care, the reports of two commissions (one privately funded and one government sponsored) have had an abiding influence on national policy.

The first was the 1910 report of Abraham Flexner's commission on the status of medical education in the United States. (9) This report resulted in producing a half-century of physicians who were trained to employ the scientific method (and distrust any conclusions that are not "proven"), focus on conducting research studies and publishing the results, develop complex medical technologies, and prefer specialty and sub-specialty practice to being a primary care practitioner.

The second was the 1992 report of the Jackson Hole Group, which advised regional health insurance purchasing cooperatives (HIPCs) as the key to "health care reform." (10,11) This report was instrumental in driving legislative and policy choices and White House initiatives in the direction of establishing the present investor-profit model U.S. health care system.

It is time for a new commission to systematically air and consider all aspects of the United States' experience thus far with managed care. This commission should list, consider, and report on successes and achievements, short-term concerns, and long-range goals.

Who should deliberate?

The newly constituted National Health Care Policy Advisory commission should be convened and funded by a private foundation active in health care policy issues. It should be endorsed by the White House and Congress, so that its recommendations have a chance of being duly considered. The commission must be free of electioneering agendas of those in public office at the time it meets. Several political views should be represented by its members. That is, the commission should include Plutocratic Republicans, Moderate Republicans, Peoples' Republicans, Businessperson Democrats, Moderate Democrats, and Roosevelt-liberal Socialist Democrats.

The focus of this commission will not be the financing of health care, yet financing realities must be considered, so a few financial experts should be included. Economists and attorneys should also be kept to a minimum. The commission should include health care executives from both investor-profit and non-profit health care organizations. These members should be counter-balanced by executives of business corporations who offer health care benefits in employee compensation packages.

The commission should include a few individuals with professional training and experience, such as physicians, nurses, and medical technicians. But it may be best if they are not official representatives of any membership body, such as the American Medical Association. The group should include those familiar with the process of establishing public policy, so that the commission's recommendations and suggested steps will be properly framed.

Finally, it is Imperative that the commission include individuals, such as university professors, who can keep this group with varied backgrounds on track when discussions range into relatively unfamiliar territory, such as the relationship between ethical behavior, peoples' rights, sociology, philosophy, the law (including Constitutional law), and how these factors relate to economic feasibility.

Starter questions?

Note that discussing health care financing mechanisms must be tabled until after exploring the following key questions outlined. That's because questions of how much money is needed, whether citizens should pay for the system through public means (taxation) or private (health care premiums and membership fees), or by increased prices made necessary by making health care a right of employment, cannot be answered until after the purposes, objectives, obligations, and prerogatives of the U.S. health care system are defined. Starter questions might include:

* Is health care a right? Or is it a privilege?

* Either way, do those controlling health care dollars have any responsibility for conserving available health care resources?

* As a result of its deliberations, does the commission suggest continuing U.S. health care policy, amending existing policy, or fundamentally changing it?

* As a result of its deliberations, what actions (by policy makers, legislators, executive groups, etc.) are recommended?

During its deliberations, commission members might do well to consider possible applications of the concept of sustainability to the U.S. health care system.

References

(1.) Thompson. Richard E., MD. Health Care Reform as Social Change. ACPE, Tampa. 1996. p. 53.

(2.) Thompson, Richard E., MD. So You've Been Integrated. Now What? ACPE. Tampa. 1996. p. 3.

(3.) Kassirer, Jerome P. Managed Care: A Look Back and a Look Ahead. NEJM. 336:14. April 3, 1997. p. 1014.

(4.) Thompson, Richard E., MD. Health Care Reform as Social Change. ACPE, Tampa. 1996. p. 3.

(5.) Walton, Mary. The Deming Management Method. New York, New York: Perigree Books, 1986. p. 34.

(6.) Foster, Rick. Sustainability: A Social Choice We Can Live With, W.K. Kellogg International Journal. 8:1, 1997. p. 4.

(7.) Thompson, Paul B., PhD. The Spirit of the Soil. London, England and New York, New York: Routledge Press, 1995.

(8.) Thompson, Paul B., PhD. Cited in the announcement of The Soul of Agriculture: A New Production Ethic for The 21st Century, a national conference held in Minneapolis, MN, November 14-16, 1997.

(9.) Flexner, Abraham, "Medical Education in the United States and Canada." Carnegie Foundation for the Advancement of Teaching. New York. 1910.

(10.) Ellwood, P.M., Enthoven, A.C., and Etheredge, L. The Jackson Hole initiatives for a twenty-first century American health care system. J Health Scon 1:149-168, 1992.

(11.) Rice, Thomas PhD, Brown, E. Richard, PhD, and Wyn. Roberta, MPH. Holes in the Jackson Hole approach to health care reform. JAMA 270:11. September 15, 1993. p. 1357.

Richard E. Thompson, MD, is author of Health Care Reform as Social Change (ACPE, 1993), and So You've Been Integrated, Now What: Opportunities for Physicians Practicing in Managed Care Settings, (ACPE, 1996). He can be reached by calling 813/789-464635, via fax at 813/789-4695, or via email [e-mail].