gic plan of choice for the future. This approach, along with more knowledgeable consumers and payers, reduction of tax subsi- dies, and efficient pricing strate- gies, has the best chance for con- taining expenditures while assuring the maintenance or im- provement of quality. Coordinat- ed care is the principle upon which the American Hospital As- sociation has developed its model dled community care networks and on which the integrated de- livery networks of the Catholic Health Association are founded.

Finally, they point out that the research community needs to de- velop more timely evaluations of efforts to improve the health care delivery system. This feedback is necessary to make course correc- tions and to minimize the nega- tive impacts of incorrect or inef- fective actions. They conclude with the belief that cost-contain- ment efforts have failed due to lack of commitment rather than a lack of effective tools. In other words, the mechanisms are avail- able to reform the health care de- livery system and contain expen- ditures while assuring quality and access. What is needed is the resolve of the American public to do so.-RGB

The Untouchables?

IO’Connor SJ, Lanning JA. The &ad of autonomy? Refiktions on the postprofessional physician. Health Care Manage Rev 1992; 17: 63-72.1

U ntil recently, virtually all health care organizations operated under dichoto-

mous management where non- physician managers “face con- straints and limitations to their own organizational power and authority.” Physician autonomy, perhaps the profession’s most sacrosanct characteristic, was

viewed as an untouchable domain.

O’Connor and Lanning de- scribe the characteristics of physician professional autonomy and the assaults on these. The characteristics of autonomy are described in terms of the who, what, why, and how of the profes- sion such as professional licen- sure, knowledge base and stan- dards, service orientation and ethics, and occupational autono- my and social policy. The as- saults on these characteristics in- clude malpractice, increased competition and specialization, questions of effectiveness in effi- cacy, potential conflicts of inter- est, managed care, and the cor- poratization of medicine. The results of these assaults on pro- fessional autonomy take the form of changing work expectations for physicians in training, a re- newed interest in practice guide- lines as a means to control costs and improve quality, the self-re- ferral brouhaha, and various third-party intrusions into the clinical decision-making process.

While physicians face a variety of changes in their practice envi- ronments that are exerting in- creasing control, the authors sug- gest that drawing battle lines will only produce losers on both sides. Different models of organization- al control from the small group practice to physician-driven or- ganizations to staff model HMOs can preserve the critical ingredi- ents of clinical autonomy.

Physicians must recognize that the profession is witnessing the end of its period of “remarkable absolute autonomy.” However complex and misunderstood are the forces leading to this change, the interest in good clinical out- comes is in large part shared by physicians and health care man- agers alike.

The authors do not believe the profession will be reduced to a “trade” unless “physicians abdi- cate responsibility for the major

POLICY WATCH

tasks of rationalizing the practice of their art.” Professional auton- omy is not unlike the mighty riv- er. Those who know the river best should ponder ways to harness that power, lest a series of dams reduces it to a controlled, man- aged, boring trickle.-MM

Rationing Managed Care- Managing Rationed Care

[Schwartz WB, Mendelson DN. my managed care cannot contain hospital costs-without rationing. Health Aff (Millwood) 1992; 11: 1ocJ-7.1

T he apple of the eye of many conservatives on both sides of the Congressional aisle, of

big business, and of President Bush’s reform package is man- aged care, their panacea for run- away costs. Some of them believe this to be the solution even with- out a heavy dose of federal (and state) control, but others see the need for a regulatory framework that nevertheless encourages competition: stipulated benefits, mandating coverage for certain technological procedures (and, by inference, excluding others); standards for tracking outcomes and reporting them to consum- ers; and, perhaps, some form of global budgeting.

As a rule these proposals favor the capitated, staff model HMO as the organizational framework, and managed care and HMO be- come entwined as though they are synonymous. It is certainly possible, as an alternative, to imagine that care can also be “managed” in other organiza- tional arrangements, including in a fee-for-service setting; at least it’s beginning to feel that way to many in practice today. The dif- ference is said to be that this is the intrusive micromanagement

November 1992 The American Journal of Medicine Volume 93 III

POLICY WATCH

of the physician-patient encoun- ter, whereas the HMO-like model depends upon macromanage- ment, with care dispensed through “networks.” This need not be a pure dichotomy; both levels of management can and probably will take place in capi- tated or in fee-for-service care, assuming the latter survives as an option, and assuming that some- how these networks actually come into the picture.

The fundamental underpin- ning for the conservative ap- proach is, of course, that the HMO has traditionally experi- enced fewer inpatient days and lower total costs per capita than in fee-for- service. However, from the late 70s until the mid-8Os, hospitalization rates fell rapidly in both settings and then began to plateau (see “End of an Era or a Cycle?“, Policy Watch, Num- ber 15, November 1991). Given

the fmdings in small area analy- ses of differences in inpatient care rates from one region to an- other, it is probable that there is still room for further reductions before an irreducible minimum in hospitalization rates is reached.

Schwartz and Mendelson ana- lyse these trends and present a convincing set of data suggesting that further reductions may be more difficult to achieve and that in any event it is not likely that large additional savings in costs can be realized (i.e., substitution of outpatient care is not free; the demographic tide of the elderly will continue; and wages in the health care industry will continue to rise).

The authors’ major point, how- ever, is that the largest factor that will continue to force costs upwards is the technological im- perative. New diagnostic and

therapeutic approaches will con- tinue to offer more-and more expensive-ways to intervene. They point out that the usually acceptable standard has been, “If it will help, do it” They contend that thii approach will have to give way to cost-effectiveness analysesandothertecbniqueafor rationalixing care. At first, they suggest, this might lead to some degree of “silent rationing,” but that phase won’t last long. Ba- tioning of a more visible and ex- plicit nature is on the way. It will be built into yearly benefits and insurance options, but the ulti- mate manager8 of managed care will be the physicians facing pa- tients and having to weigh some wrenching decisions. They’ll be rationing managed care while trying to manage rationed care. Perhaps it is time for society to help them work out the ground rules.-WPB

I

1 POLICY SPEAK 1 “On an average day, 3.5 million people seek care from wagon for providing universal health care coverage to all , a doctor, and an additional 870,000 people are hospital- of its citizens. In discussing his initiatives, Governor (and

ized under the care of the physician. Even though direct medical doctor) Howard Dean comments: payments to physicians account for only 20 percent of “Vermont is a small state (43rd in size and 48th in total health care expenditures, physicians influence a population), and we are accustomed to doing things for much larger share of the spending, because they make ourselves. Once, such independence was by choice. the decisions to order tests, prescribe drugs, and admit Now, often it is, by necessity. a situation altr&table to patients to the hospital.. .For this reason, awareness of federal neglect. changing trends in physician practice is critical to an Only the national government has the capacity, and understanding of the health care system.” the responsibility, to guarantee all citizens access to

-Leitman R, Taylor H, Edwards JN. Physicians’ health care. But the Congress and the President have responses to their changing environment. J Am Health

Policy 1992; 2: 35. abdicated that duty.”

-Dean H. Doctor Dean’s prescription for health Vermont has joined the state health care reform band- care reform. J Am Health Policy 1992; 2: 7~.

IV November 1992 The Amerkan Journal of Yediclne Volume 93