The death of managed care? (A Member Responds).

As I previewed the lead articles in this issue of The Physician Executive, I was captured by the uniting theme of risk--risk as it applies to physician executives in particular. We, as medical managers and leaders, continue to face burgeoning, indeed pioneering, concepts in the process of delivering health care. Today, it appears that the pendulum of managing this process has swung precariously close to those of us in leadership roles. In the words of Earl R. Washburn, MD, "An increasingly contentious climate makes the work of physician executives more difficult and sensitive."

Increasingly, class action lawsuits are being filed against academically-oriented facilities and schools. At the same time, an expanded definition of health care delivery is emerging. Does a medical director who makes a decision about a specific episode of care engage in the practice of medicine, or does she act as intercessor for the fiduciary agent of her company...or both?

These are not easy questions to answer. David O. Weber addresses this quandary in his article on "Managed Care Medical Directors Under Fire." On the one hand, the medical director must use her medical judgement, and to that extent, perhaps, she may be said to be practicing medicine. Yet that same medical director, using that same judgement, could as easily be said to be exercising her fiduciary responsibility by declaring that her company will not pay for that episode of care due to specifications of the contract that governs the encounter. She is not denying care--she is declining to pay for the care. This is not an absolute either/or issue.

Consumers driving managed care reform

George P. Young, JD, the Texas lawyer involved in HMO litigation, concludes in his interview that all of these issues are important, but that in the end it will be the consumer who will drive the most significant change. His view reminds me of Regina Herzlinger's excellent book Market-Driven Healthcare: Who Wins, Who Loses in the Transformation of American's Largest Service Industry (Perseus Books, 2000). Her premise is the same as Young's. I believe that they are correct...in this country and at this time. As Young said, "the burgeoning consumer-driven health care movement--featuring defined contributions for employees, consumers shopping for plans over the Internet, and the demand for health plan choice--may be as powerful a force as legal actions in bringing about managed care reform." I'd add...and perhaps even more powerful.

I discovered a second unifying theme among these articles--one that I will use in my vision for our health care system in the United States Air Force--and it is death. These lead authors believe managed care as we know it will be dead in ten years or less--perhaps much less. A shift is occurring that physician executives need to influence and direct. At the American College of Physician Executives, our new philosophy of "Leading Beyond the Bottom Line" fits perfectly into this creative environment. It's exciting when you see things coming together, and I believe they are...right here, right now.

Major General Leonard M. Randolph, Jr., MD, MS, FACS, CPE, FACPE, is President of the American College of Physician Executives and Special Assistant to the Surgeon General at Boiling Airforce Base in Washington, D.C. He can be reached by calling 202/767-4767 or via email at [e-mail].