The Consequences of Managed Competition

Disturbing the partnership between generalists and specialists diminishes the quality of health care.

Dr. Cangello is a private practitioner in Oakland, California.

Under managed competition the primary care physician takes complete charge of the patient’s health care. The primary care physician is encouraged, and often financially rewarded, to limit and reduce the number of patients he refers to a medical or surgical specialist.

Under managed competition, a female patient, for example, loses her prerogative to see a gynecologist unless she first obtains the permission of her primary care physician to make such a visit.

The limiting of referrals, a basic concept of managed health care, is in direct conflict with the structure of American medical education and the medical profession. Such limits can cause primary care physicians and general practitioners to prescribe care at levels that exceed their knowledge and training. When this occurs, the patient runs the risk of receiving improper care.

Evidence of this was provided by American Medical News on September 14, 1992, when it was reported that malpractice lawsuits filed against primary care physicians are on the rise while those against surgical specialists are declining.

Timothy Morse of St. Paul Fire and Marine Insurance Company, which insures 30,000 doctors in 43 states, told American Medical News that “Well over 50 percent of our claims made and over 65 percent of all our claims paid are coming from failure to diagnose and improper treatment.”

Medical patients should know that the body of medical information facing today’s medical students is so immense that it is virtually impossible for any one doctor to become expert and stay abreast of all its advances.

Physicians specialize in order to master a subject, not merely in order to make more money, as they are often accused. Such an accusation fails to show appreciation for and gives no credit to the students who choose to be specialists for the “security of mastery” or for the enjoyment of the work involved.

Americans today want the best care available, regardless of cost and despite any reluctance to reform bad health habits. They will bring suit against the doctor if they don’t get it. With that reality in mind, medical students who choose to become primary care physicians are taught to respect the limits of their ability and to seek the benefit of consultation with medical and surgical specialists, without hesitation, whenever necessary.

This basic tenet of the American medical training, which has produced a quality of health care envied throughout the world, is discouraged by the “primary care/gatekeeper” concept of managed competition.

A review of British medical history demonstrates that any reduction of communication between primary care physicians and their consultants leads to the separation and eventual isolation of the primary physicians and guarantees an overall lowering of the quality of health care available to their patients.

Frank Honigsbaum, an American physician, studied these phenomena and wrote in his report “Division in British Medicine” (Kogan Page Ltd., 1979): “To the world outside, the medical profession [in England] appears to form a unitary whole.” In reality, however, “Doctors nearly every where are divided into two main classes—General Practitioners and Specialists—and the gap between them grows wider every year. For this, the advances in knowledge are mainly responsible.” He emphasized that “It is the ongoing intellectual partnership and exchange of knowledge occurring between the generalists and specialist [the traditional practice in the U.S.] that keeps the quality of medical care at its best.”

If this partnership is disturbed, as it was in the British National Health Service, the quality of care diminishes throughout the system, and especially at the primary care level.

A correct diagnosis and proper care at the outset of a patient’s illness will do more to reduce the cost of care than any restriction of appropriate consultation. It would be better to err on the side of an unnecessary consultation than not to have one at all.

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